Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided June 19, 2019 to
June 30, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that this should be considered a new
SNF stay because the second stay was for a different diagnosis. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay $0 copayment per day, days 1-20 at an in-network skilled nursing facility and a $135 copayment per
day, days 21 to 100 for an in-network skilled nursing facility.
You have been asked to pay an $810 copayment for the SNF stay. The SNF stay falls within the "Skilled
nursing facility (SNF) care" benefit category. The record shows the second SNF stay was within the same
benefit period as the first SNF stay. See chart below.
Dates of
Service
Service Copayment
per Day
SNF Days Number of
Days
Member
Liability
May 21, 2019-
June 4, 2019
SNF stay $0 1-14 14 $0
June 19, 2019-
June 24, 2019
SNF stay $0 15-20 6 $0
June 25, 2019-
June 30, 2019
SNF stay $135 21-26 6 $810
Total $810
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the SNF stay provided from June 19, 2019 to
June 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical extraction for tooth # 2.You asked the Plan to pre-approvea surgical extraction for tooth # 2. The Plan denied your request. The Plan says the records submitted do not support the need for a surgical extraction.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the surgical extraction of tooth # 2 when the services are medically necessary and reasonable. 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 the surgical extraction of tooth # 2. Our reviewer says that the surgical extraction of tooth # 2 is not medically necessary. Our physician reviewer found based on the documentation provided, the removal of the residual roots of tooth # 2 would not require a surgical extraction, a cutting procedure, as noted by code D7250.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical extraction of tooth # 2 have not been met.Therefore, we decided that the Plan does not have to pre-approvea surgical extraction for tooth # 2
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.You asked the Plan to pre-approve Myrbetriq. You say that the enrollee has failed other medications.The Plan denied your request. The Plan says Myrbetriq to be taken at home is not covered under the Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generallydoes 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-approveMyrbetriq.Benefits for Myrbetriqmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature with harness.You asked the Plan to pre-approvepower seat elevation feature. You say that this feature will help you maintain your independence at home and be able to use the chair in wheelchair vans.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because a power seat elevation feature is not primarily medical in nature and is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that power seat elevation features are not primarily medical in nature and are not covered by Medicare. We lookedat the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation feature have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature with harness.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig.You asked the Plan to pre-approveAimovig. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveAimovig. Benefits for Aimovigmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthoracoscopyand thoracotomy services provided to the enrollee on July 18, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes were 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 the denied codes is:CPT 32601:Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsyCPT 32505:Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial We asked our coding 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 pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT 32505, per NCCI edits, has a unbundle relationship with CPT code 32480 which was billed on the same date of service, on the same claim and was paid. CPT 32505 is a column II code and CPT code 32480 is a column I code. Per NCCI edits, a modifier is allowed to unbundle the codes providing criteria of the chosen modifier is met in the operative note. However, there was no appropriate modifier chosen or billed with CPT code 32505, therefore it cannot be considered for reimbursement. CPT code 32601 has been identified as a service thatis either not reasonably performed on the same date of service as other procedures that were performed or the code (32601) does not meet correct code editing guidelines. Per NCCI edits, a modifier is allowed to unbundle the codes providing criteria of thechosen modifier is met in the operative note. However, there was no appropriate modifier chosen or billed with CPT code 32505, therefore it cannot be considered for reimbursement. We looked at this coder's review, the file, and Medicare rules. 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 pay forthoracoscopy and thoracotomy services provided to the enrollee on July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee anthroplasty (27447).
You asked the Plan to pre-approve the knee anthroplasty. You say that the custom implants are necessary to balance the member's gaps in flexion and extension. The Plan denied your request. The Plan says the clinical value and effectiveness of custom knee implants has not been established.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the knee anthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support the need for custom implants. Traditional implants may be used safely and effectively. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee anthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee anthroplasty (27447).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer System.
You asked the Plan to pre-approve a Vertiflex Superion Interspinous Spacer System. You say that the requested Vertiflex Superion Interspinous Spacer System is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex Superion Interspinous Spacer System is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 a Vertiflex Superion Interspinous Spacer System. Our reviewer says that the requested Vertiflex Superion Interspinous Spacer System is not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis and neurogenic claudication. She has failed conservative therapy including bracing, Physical therapy, epidural steroid injections and medication trials of opiates and NSAIDs. The Vertiflex system is an experimental/investigational procedure that has not had a head to head trial versus laminectomy and a long enough follow-up period. Too many of the patients have been lost to follow-up. Therefore, the requested procedure is deemed not medically reasonable or necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion Interspinous Spacer System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis, and suspension
sleeve provided on June 21, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648), the knee orthosis (L1851), and suspension
sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan
says criteria were not met.
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 pay for the lumbar-sacral orthosis (L0648), the knee
orthosis (L1851), and suspension sleeve (L2397). Our physician reviewer found the enrollee's chief complaints
were lower back pain and left knee pain. The available documentation in the case file does not support that the
requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case,
according to the coverage criteria established by the LCD. A physical examination of the back would
reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The
documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the
covered indications in this case, as there is insufficient documentation of a credible physical examination of the
back.
The documentation in the case file does not support that the requested knee orthosis and sleeve were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and
there is insufficient credible objective documentation of joint laxity.
The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the lumbar-sacral orthosis (L0648), the knee orthosis (L1851), and suspension
sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral
orthosis, the knee orthosis, and suspension sleeve provided on June 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePregabalin 100mg capsule.You asked the Plan to pre-approvePregabalin 100mg capsule. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not includePart D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administereddrugs 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-approvePregabalin 100mg capsule.Benefits for Pregabalin 100mg capsulemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on June 17, 2019 and July 1, 2019.You asked the Plan to waive the copayments forthe office visits. You say that the doctor didn't do anything for you. You say that you should be refunded your copayments.The Plan denied your request. The Plan says the copayments 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 $50 for each Medicare-covered visit withan in-network specialist. You have been asked to pay a $50 copayment for each office visit. The total amount you owe is $100 ($50/visit x 2 visits = $100). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments forthe office visits provided on June 17, 2019 and July 1, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment forthe outpatient clinic visit provided on August 10, 2019.You asked the Plan to waive the copayment forthe outpatient clinic visit. You say that you were informed the visit would be anurgent carevisit. You say that you should not have to pay the emergency roomcopayment.The Plan denied your request. The Plan says that the copayment applied correctly.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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide documentation to support that this service was provided in an emergency room place of service or that this visit was emergency care in nature. You say that this visit was not an emergency room visit, and you were told this would be treated as an urgent care visit. Without supporting documentation, the Plan has not shown that its decision to apply the emergency care copayment to this claim is correct or justified by the health plan contract. Furthermore, the Plan contract does not clearly state how much enrollees must pay for outpatient hospital clinic visits or for urgently needed services provided in an outpatient hospital.Therefore, we decided that the Plan has to waive the copayment forthe outpatient clinic visit provided on August 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora magnetic resonance imaging (MRI) of the right middle finger and knuckle (73218RT) provided on December 18, 2018.You asked the Plan to pay forthe MRI of the right middle finger and knuckle. You say that you do not feel you should be responsible for the copayment since you never received your results.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for advanced imaging services. You have been asked to pay $200 for the MRI of the right middle finger and knuckle. An MRI of the right middle finger and knuckle falls within the advanced imaging services 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 pay fora magnetic resonance imaging (MRI) of the right middle finger and knuckle (73218RT) provided on December 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on July 16, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you were not informed of the cost.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 10% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on July 16, 2019. The allowed amount is $2,439.12 and 20% of that is $243.91. You have been asked to pay the total coinsurance amount of $243.91 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance fora Medicare Part B drug injection provided on July 16, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF. You say that the enrollee is in need of rehab. You say that you would like to discharge the enrollee so that she can get back to herself. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The plan says that the enrollee can receive the care needed in another setting
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 the SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has pain which needs to be assessed and treated. The enrollee requires oversight of her medical conditions and medication management. The enrollee is at risk for secondary complications related to constipation, as well as a recurrence of the abscess. The enrollee has not returned to her prior level of function. The enrollee requires physical therapy for progression of her mobility and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. While there are skilled needs, they do not need to be provided on a daily basis. The enrollee is ambulating greater than household distances, has been progressed to stair climbing, and is performing essential activities of daily living without hands on assistance. The enrollee is receiving care that can be provided by her non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily basis.
The enrollee's care can be appropriately provided through home-based and outpatient services. If stair climbing is an issue, this would most appropriately occur on the actual stairs in the home setting. Rearrangement of the living space (e.g. setting up a bed on the first floor) or use of adaptive equipment (e.g. commode) would be examples of ways in which a stair climbing deficit could be addressed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided on August 6, 2019, August 13, 2019, August 27, 2019 and September 17, 2019.
You asked the Plan to waive the copayments for wound care. You say that this shouldn't be considered surgery or debridement. You say that this shouldn't cost you $200 per visit. The Plan denied your request. The Plan says the copayments 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 $200 copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital setting. You have been asked to pay $172.92, which is less than the standard $200 copayment for each wound care visit. The total amount you owe is $691.68 ($172.92/visit x 4 visits = $691.68). Wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for wound care provided on August 6, 2019, August 13, 2019, August 27, 2019 and September 17, 2019.