Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital.

You asked the Plan to waive the copayment for wound care. You say that you thought that your copayment would be $50. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient surgery/in-network.

You have been asked to pay less than a $225 copayment for each wound care. The total amount you are being asked to pay is $1,928.93 which is less than your total copayment amount of $2,025 ($225 x 9 visits = $2,025). Wound care falls within the outpatient surgery/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the pneumatic compression device. You say that there is no in network alternatives. The Plan denied your request. The Plan says there is an in-network alternative. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ear/nose examination and office visit provided on October 13, 2020.

You asked the Plan to waive the copayments for diagnostic procedure and office visit. You say that you only had 1 visit so should only be charged 1 copayment. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 copayment for each simple diagnostic procedure and $20 copayment for each office visit with an in-network provider. Your total copayment obligation is therefore $40. 

You have been asked to pay $20 copayment for diagnostic procedure and $20 copayment for office visit. Diagnostic procedure and office visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an ear/nose examination and office visit provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 13, 2020.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on July 2, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 64490 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 64490 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level. 

We find that CPT code 64490 is not supported in the medical record. Specifically, there is no documentation of a paravertebral facet joint injection with imaging guidance of a single cervical or thoracic level. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services rendered on July 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on November 4, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that this was an unnecessary ultrasound. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient diagnostic tests/in-network/diagnostic radiology services/ultrasound. You have been asked to pay a $100 copayment for an ultrasound. 

The correct copayment has been applied to the diagnostic ultrasound that was provided. An ultrasound falls within the outpatient diagnostic tests/in-network/diagnostic radiology services/ultrasound benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoskeletal knee-shin systems (L5814, L5848), a multiaxial ankle (L5968), and a flex-walk system (L5981).

You asked the Plan to pre-approve endoskeletal knee-shin systems, a multiaxial ankle, and a flex-walk system. You say that these items are necessary for the enrollee's basic needs. The Plan denied your request. The Plan says these items exceed the enrollee's needs.

The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal is covered for beneficiaries whose functional level is 3 or above. A fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose functional level is 3 or above. An axial rotation unit is covered for beneficiaries whose functional level is 2 or above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve endoskeletal knee-shin systems, a multiaxial ankle, and a flex-walk system. Our reviewer says that the criteria for coverage of the requested items have not been met. Our physician reviewer found the submitted medical records do not include objective documentation supporting that the patient is a K3 ambulator. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endoskeletal knee-shin systems, a multiaxial ankle, and a flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve endoskeletal knee-shin systems (L5814, L5848), a multiaxial ankle (L5968), and a flex-walk system (L5981).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the inpatient skilled nursing facility (SNF) care provided from July 24, 2020, through August 22, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the inpatient skilled nursing facility care provided was not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide the medical records for the inpatient skilled nursing facility care rendered in this case. Therefore, we decided that the Plan has to pay for the inpatient skilled nursing facility (SNF) care provided from July 24, 2020, through August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of failed conservative treatment.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

No medical records were provided despite several attempts by the plan. It cannot be determined if the enrollee has the indications for the requested procedure. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on June 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code S8037 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code S8037 (magnetic resonance cholangiopancreatography [mrcp]) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on June 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy tablets.

You asked the Plan to pre-approve Ubrelvy tablets. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy tablets.

Benefits for Ubrelvy tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS emergency ambulance services (A0427) and ground mileage (A0425) provided April 27, 2020.

You asked the Plan to pay for the ambulance services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on 04/27/2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ALS emergency ambulance services (A0427) and ground mileage (A0425) provided April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation that you meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac injection.

You asked the Plan to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). You say that you need chronic back pain relief. The Plan denied your request. The Plan says that the records do not show the enrollee's sacroiliac joint is inflamed or swollen.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found a magnetic resonance imaging of 9/11/20 states: "moderate bilateral SI joint osteoarthritis". The request is medically reasonable and necessary and is fully supported by advanced imaging. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096) have been met. Therefore, we decided that the Plan has to pre-approve a sacroiliac injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by non-certified provider.You asked the Plan to pre-approveseat lift mechanism. You say that you wouldlikeanexplanation of as to how her provider is not a provider of Medicare. You are asking that your claim be overturned for payment as the letter stated that you received.The Plan denied your request. The Plan says the provider isnot a Medicare certified provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. But the Plan will not pay or approve non-certified providers. The requested provider in this case is not a network or non-network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by non-certified provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation provided does not support that you require, or could participate in, at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. The documentation in the case file raises doubt as to whether there is a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the abdomen (76705) provided September 25, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you should not be responsible for the entire adjusted amount. The Plan denied your request. The Plan says the enrollee's cost-share was less than the required copayment and therefore the cost-sharing was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered radiological diagnostic service, not including Xrays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay $89.54 as your copayment for the ultrasound. This service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound of the abdomen (76705) provided September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation provided does not support that you require three hours of therapy per day for at least five days per week, or 15 hours over 7 consecutive days, of therapy services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 20, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on October 20, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 20, 2020.