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

We decided that the Plan does not have to pre-approve three Euflexxa injections (J7323 x3).

You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee would benefit from Euflexxa. The Plan denied your request. The Plan says the documentation does not show that the enrollee has failed physical therapy or has tried a steroid injection into their knee which did not help. The Plan also says that the enrollee has not tried and failed a similar injection.

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 the Euflexxa injections. Our reviewer says that the medical necessity criteria have been met for approval of this drug. Our physician reviewer found the Plan requires a trial of drug Gel-One, Orthovisc, Synvisc, Synvisc- One, or Visco-3 before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) 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 the Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve three Euflexxa injections (J7323 x3).
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 on November 18, 2020, to March 26, 2021.

You asked the Plan to waive the copayment for a knee injection. You say that this was outpatient. You say that this should not be considered surgical. 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 $200 copayment and a $150 copayment for outpatient surgery/in-network/outpatient hospital.

You have been asked to pay a $200 copayment and a $150 copayment for a knee injection. The total amount you are being asked to pay is $550 ($200 + $200 + $150 = $550). The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. The knee injection that you received falls within the outpatient surgery/in-network/outpatient hospital 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 provider on November 18, 2020, to March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the current acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the x-ray services provided on March 11, 2021.

You asked the Plan to waive the copay for the x-ray. You say that the x-ray was done in the provider's office. The Plan denied your request. The Plan says the appropriate copay was 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 $30 copay for each Medicare-covered x-ray. 

You have been asked to pay a $30 copay for the x-ray services. The x-ray falls within the outpatient diagnostic tests 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 copay for the x-ray services provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (99233) provided December 22, 2020.
You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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. We find that CPT code 99233 is not supported in the medical record. Specifically, a required modifier (GG) was not appended to the appropriate corresponding service. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (99233) provided December 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on February 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the behavioral health services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 behavioral health services provided on February 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the ophthalmology visit. You say that your doctor is not willing to continue treatment without insurance approval. You say you have a history with the provider. The Plan denied your request. The Plan says there is a lack of medical necessity for out-of-network care.
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 provider at issue in this case is not a network provider with the Plan. 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 ophthalmology visit. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the records indicate the planned services are not related to the procedure follow-up.
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 ophthalmology visit have not been met. 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 the ophthalmology visit. Therefore, we decided that the Plan does not have to pre-approve the ophthalmology visit 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 pay for the anesthesia care provided on July 27, 2020.
You asked the Plan to pay for the anesthesia care. 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 pay for the anesthesia care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee is not on any psychiatric medications, is not morbidly obese, and does not have Obstructive Sleep Apnea or other indications for Monitored Anesthesia Care. The sedation was 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 anesthesia care have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia care provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene analysis services provided on September 11, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.
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 looked at the file and the rules. The records do not show that more than one single procedure was performed for the testing. Only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene analysis services provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on September 2, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not performed by a physician.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not indicate the services were provided by a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on September 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the Medicare criteria for appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1851), and suspension sleeve (L2397),
provided on September 21, 2020.
You asked the Plan to pay for the knee orthoses and suspension sleeve. You say that the items are medically
necessary. The Plan denied your request. The Plan says documentation submitted did not include an itemized
shipping/billing invoice to indicate the specific supplies, or proof of delivery from the billing provider.
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for orthotics to be
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 pay for the knee orthoses and suspension sleeve.
Our reviewer says that the items are not medically necessary. Our physician reviewer found 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 knee orthoses and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthoses (L1851), and suspension sleeve (L2397),
provided on September 21, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81230, 81479, 81110, 81241) provided October 15, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure.
We looked at the file and Medicare rules. Multiple unbundled codes were billed for the panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81230, 81479, 81110, 81241) provided October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider took the specimen and sent it to the lab for analysis. The Plan denied your request. The Plan says services provided by non-participating 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the plan. The Plan had network providers available who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the lab services provided on March 10, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile airway clearance therapy vest (AffloVest) (E0483), provided February 8, 2021.
You asked the Plan to pay for the AffloVest. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee has no diagnosis of bronchiectasis associated with COPD.
The Plan follows Medicare rules. Medicare rules say that certain criteria must be met for high frequency chest wall oscillation devices to be 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 pay for the AffloVest. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee has no diagnosis of bronchiectasis associated with COPD. 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 AffloVest have not been met. Therefore, we decided that the Plan does not have to pay for the mobile airway clearance therapy vest (AffloVest) (E0483), provided February 8, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428, A0425) provided on August 20, 2020.
You asked the Plan to pay for non-emergency ambulance transportation. You say that the transport was medically necessary. The Plan denied your request. The Plan says the criteria for a non-emergency transport have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency ambulance transportation. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation did not support that other means of transport (such as stretcher van, or wheelchair van) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully equipped ambulance can provide for safe transport. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation have not been met. Specifically, the ambulance transport was not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428, A0425) provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 30, 2020 to October 20, 2020.
You asked the Plan to pay for the acute inpatient level of care. You say that you believe that acute inpatient level of care was warranted based on the enrollee's medical and behavioral health issues. The Plan denied your request. The Plan says the enrollee does not require acute hospital level of care. Care could have been rendered at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting. 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 acute inpatient level of care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee presented to the emergency department due to concern of allergic reaction to antibiotic. The enrollee has bipolar disorder inadequately controlled. The enrollee has endocarditis with valvular vegetation. The enrollee's signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting. The admission note indicates that psychiatry opined that the enrollee did not have capacity to decline treatment or leave hospital but could not be force medicated. Capacity is situational. The enrollee could not be safely managed in a lower level of care. The admitting physician documented the expectation of inpatient admission. The elements of the coverage rule are satisfied. 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 acute inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 30, 2020 to October 20, 2020.