Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provide from October 13, 2020, through October 14, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the non-participating provider did not request authorization from the plan.
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 inpatient admission. 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 an inpatient admission provide from October 13, 2020, through October 14, 2020.
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 provider.

You asked the Plan to waive the copayment for nail debridement. You say that you never had to pay a copayment for this before. 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 $200 copayment for outpatient surgery/in-network.

You have been asked to pay $57.83 which is less than your copayment amount of $200 for nail debridement. Nail debridement falls within the outpatient surgery/in-network benefit category. The correct copayment has been applied to the services provided. 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 provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's 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 physician's services provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on November 9, 2020.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says the services required 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 ophthalmological 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 ophthalmological services provided on
November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chiropractic visits provided on May 5, 2020 and September 1, 2020.

You asked the Plan to waive the copayments for the chiropractic visits. You say that you should not owe a copayment. You say you have been receiving on-going chiropractic care and have not been charged anything for those visits. The Plan denied your request. The Plan says you have been asked to pay 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). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered chiropractic services at an out-of-network specialist's office. 

You have been asked to pay a $20 copayment for each of the chiropractic visits. The chiropractic visits fall within the "Chiropractic 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 waive the copayments for the chiropractic visits provided on May 5, 2020 and September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation charges for mobile radiology services.

You asked the Plan to pay for the transportation charges. You say that this should be covered as it was necessary to bring the equipment to the facility in which the enrollee resides. The Plan denied your request. The Plan says this is not payable with the reported POS code.

The Plan must follow Medicare rules. Medicare rules say that POS code 31 is used for enrollees who are in a Part A covered SNF stay. The rules say that transportation charges for mobile radiology cannot be paid for those in a Part A stay.

In this case, the POS code 31 was reported. As such, the transportation charges cannot be separately billed in this instance. Payment is made to the SNF in the Part A payment. Therefore, we decided that the Plan does not have to pay for the transportation charges for mobile radiology services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided by an out of network (OON) provider.

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the provider in this case is out of network. The Plan also says that authorization was not obtained before the services were rendered to the enrollee.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home health services provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for radiation therapy. We decided that the Plan does not have to waive the coinsurance for radiation therapy.

You asked the Plan to waive the coinsurance for radiation therapy. You say that you do not agree with this decision. The Plan says that the correct coinsurance has been applied.

We decided that the Plan has to reduce the coinsurance for radiation therapy.

You cannot be asked to pay more than 20% coinsurance of the allowed amount for radiation therapy. The total allowed amount is $14,548.13. The total amount you are being asked to pay is $2,909.63 ($14,548.13 x 20% = $2,909.63). Therefore, we decided that the Plan has to waive the coinsurance for radiation therapy.

We also decided that the Plan does not have to waive the coinsurance for radiation therapy.

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 20% coinsurance of the allowed amount for radiation therapy. Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat bilateral lumbar facet joint injections.
You asked the Plan to pre-approve repeat bilateral lumbar facet joint injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested repeat bilateral lumbar facet joint injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare covers repeat therapeutic facet joint injections if the first injection results in significant pain relief (greater than 50%) for at least 3 months. The file shows the enrollee received the first injections on January 14, 2021, which is less than 3 months ago. A new request can be made for authorization once the 3 months have passed. Based on this information, we decided that Medicare rules for coverage of repeat bilateral lumbar facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat bilateral lumbar facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance service (D4910).

You asked the Plan to pay for periodontal maintenance. You say that the Plan should cover periodontal maintenance because it is similar to other services that are covered. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Although the Plan does cover some services that are similar, procedure codes (such as D4910) are assigned to separate and distinct services. The specific service provided is not among those that the Plan covers. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance service (D4910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient consultation (99253) provided on April 15, 2020.
You asked the Plan to pay for an inpatient consultation. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99253 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99253) provided on April 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. X-rays demonstrated several levels of degenerative retrolisthesis and spondylolisthesis without abnormal motion when comparing flexion and extension radiographs. There is imaging evidence of levoscoliosis centered in the mid lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. Therefore, the request for Superion interspinous spacer is not medically reasonable or necessary. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found, you did not require any skilled nursing or rehab services on a daily basis. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on July 12, 2020.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the record. Specifically, the documentation submitted does not support that more than 30 minutes if discharge day management services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on July 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (E1399, A4467, E0118) provided on October 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (E1399, A4467, E0118) provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Promethazine for the enrollee.
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an endodontic therapy.
You asked the Plan to pay for the endodontic therapy. You say that you need this service. The Plan denied your request. The Plan says endodontic therapy is not a covered benefit.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an endodontic therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that this is necessary for the enrollee's
condition. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. Open laminectomy is the gold standard of treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).