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

We decided that the Plan does not have to waive the copayment for outpatient hospital services, specialist services, and an outpatient diagnostic test provided by participating providers that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied to the services that were provided.
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 $150 copayment for outpatient hospital services/services performed at an outpatient facility, a $45 copayment for physician/practitioner services/specialist, a $50 copayment for outpatient diagnostic tests/in-network/diagnostic tests. You have been asked to pay $110.49 which is less than your copayment amount of $150 for outpatient hospital services. You have been asked to pay a $45 copayment for specialist services. You have been asked to pay $8.94 which is less than your copayment amount of $50 for an outpatient diagnostic test. Outpatient hospital services falls within the outpatient hospital services/services performed at an outpatient facility benefit category, specialist services fall within the physician/practitioner services/specialist benefit category, and an outpatient diagnostic test falls within the outpatient diagnostic tests/in-network/diagnostic tests benefit category. The total amount you are being asked to pay is $164.43 ($155.49 + $45 + $8.94 = $164.43). 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 outpatient hospital services, specialist services, and an outpatient diagnostic test provided by a participating provider on July 16, 2020, to January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zilretta.
You asked the Plan to pre-approve Zilretta. You say that the enrollee has tried and failed Euflexxa in the past. The Plan denied your request. The Plan says the denial of authorization for Zilretta is correct, because the Plan requires a trial of dexamethasone, methylprednisolone, and triamcinolone before it will approve Zilretta.
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 Zilretta. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Zilretta. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of dexamethasone, methylprednisolone, and triamcinolone. The record does not show that these drugs would likely be less effective and/or 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that there are in-network providers available 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 physician services provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network office visit at the in-network rate.
You asked the Plan to pre-approve the out-of-network office visit at the in-network rate. You say that the services are medically necessary and should be covered at the in-network rate. The Plan denied your request. The Plan says there are network providers available that can provide these services. The enrollee can receive the services at the out-of-network rate.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network office visit at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a debridement (11044, 11047) provided August 4, 2020.
You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan denied your request. The Plan says documentation does not support the services 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 11044 & 11047 is not supported in the medical record. Specifically, the record does not show that the debridement involved the bone. Based on this information, we decided that Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the Plan does not have to pay for a debridement (11044, 11047) provided August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diagnostic or Therapeutic Injection, a shot of pain numbing substance used to diagnose or treat pain delivered using imaging (special pictures) to guide the injection (CPT code 62323), for the enrollee.
You asked the Plan to pre-approve the service. You say that the services are necessary. The Plan denied your request. The Plan says the procedure requested is not supported without a treatment plan showing that the enrollee will not exceed the following limits. The Plan states no more than two (2) injections to the area where a nerve root exits (transforaminal) can be done during a single setting. The Plan states this includes one spinal level on both sides of the enrollee's spine or two spinal levels on one side of their spine, and no more than one injection to the space near the enrollee's spinal canal can be done per session.
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 service. Our physician reviewer found the documentation does not support that the enrollee has pain severe enough to cause some degree of functional deficit and that there has been failure of at least four weeks of non-invasive care. Furthermore, the level at which the proposed epidural steroid injection (ESI) would be performed is not specified. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Diagnostic or Therapeutic Injection, a shot of pain numbing substance used to diagnose or treat pain delivered using imaging (special pictures) to guide the injection (CPT code 62323), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral supplies provided from February 2, 2020, to February 29, 2020.
You asked the Plan to pay for the enteral nutrition infusion pump (B9002), enteral feeding supply kit (B4035), and enteral formula (B4150). You say that the enrollee was not receiving skilled services covered by the Plan. The Plan denied your request. The Plan says the Place of Service on the claim is 31, patient in a Part A covered stay.
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. Records show that the enteral nutrition infusion pump (B9002), enteral feeding supply kit (B4035), and enteral formula (B4150) were used in a SNF. The facility must furnish all necessary covered supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies would have been included in the global payment submitted to the plan by the facility. If the health plan is not covering the SNF stay, the cost of these supplies is absorbed by the facility. Payment for this claim must be submitted to the facility for payment, not the health plan. Therefore, we decided that the Plan does not have to pay for the enteral supplies provided from February 2, 2020, to February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).
You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebroplasty surgery.
You asked the Plan to pre-approve percutaneous vertebroplasty surgery. You say that the enrollee's doctors recommend this as the best treatment for him. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is excluded for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules state that percutaneous vertebral augmentation procedures may be covered for certain indications but are not indicated for treatment to the sacrum or coccyx area. 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 percutaneous vertebroplasty surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested surgery. Our physician reviewer found the enrollee has previously undergone thoracic kyphoplasty procedures. The enrollee reported a significant improvement in pain. A Computed Tomography (CT) scan demonstrated bilateral sacral insufficiency fractures which are new on the right. Medicare rules state that this procedure is not indicated for the sacrum or coccyx. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebroplasty surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebroplasty surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty and brow repair surgery.

You asked the Plan to pre-approve blepharoplasty and brow repair. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is
correct, because the enrollee does not meet any of the criteria for coverage.

The Plan follows Medicare rules. Medicare rules state that blepharoplasty and brow repair may be covered
under certain condition and if certain documentation requirements are 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 pre-approve blepharoplasty and brow repair. Our
reviewer says that the enrollee does not meet the Medicare criteria for the requested surgical services. Our
physician reviewer found the enrollee presents with complaints unrelated to vision. The documentation is
insufficient to show that the enrollee satisfies the other elements of coverage for these services. The requested
services cannot be recommended 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 blepharoplasty and brow repair have not been met. Therefore, we decided that
the Plan does not have to pre-approve blepharoplasty and brow repair surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular electrical stimulation device.

You asked the Plan to pre-approve the auricular stimulator. You say that this should be covered as a non-invasive pain relief treatment. The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that devices which stimulate auricular nerves are electroacupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an auricular electrical stimulation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve these services. You say that you have neuropathy, severe arthritis, and three hand surgeries and cannot pick up strips. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you are not performing blood glucose checks four or more times per day. 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 pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued visits for lymphedema treatment.
You asked the Plan to pre-approve the continued visits for lymphedema treatment. You say that you have a
chronic, incurable disease and must have your provider check your numbers and get measured annually. The
Plan denied your request. The Plan says that you have had 15 manual therapy visits and you have received the
benefit needed from the visits; therefore, going back to check your numbers on a periodic basis is not medically
necessary. You are able to do home treatment and there are no indications of any reasons why you might not be
able to follow home treatment.
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 continued visits for lymphedema
treatment. Our reviewer says that the requested continued visits for lymphedema treatment are not considered
medically reasonable and necessary. Our physician reviewer found that your condition is chronic and noted as
stable. You have had extensive prior treatment for this condition, and you have been educated in treatment and
self-care. The requested continued visits exceed your medical need and are not medically 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 continued visits for lymphedema treatment have not been met. Therefore,
we decided that the Plan does not have to pre-approve continued visits for lymphedema treatment.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 10 additional physical therapy visits.
You asked the Plan to provide 10 additional physical therapy visits. You say that you believe the enrollee
would benefit from continued therapy to address impairments and functional limitations to avoid falls. The
Plan denied your request. The Plan says 10 additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 provide 10 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the member has had 10 sessions with a physical
therapist and has shown an improvement in mobility and strength. The enrollee should be independent with a
home exercise program. The requested number of physical therapy sessions are considered excessive and not
medically 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 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to provide 10 additional physical therapy visits.
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 the enrollee is stable and will require extended acute care, so LTACH is the appropriate level of care. 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 she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies to
be provided by an OON provider.
You asked the Plan to pre-approve OON services. You say that the enrollee has trouble breathing. The Plan
denied your request. The Plan says there are providers available in-network that can provide the care needed.
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 file shows that a full mask, headgear, face mask interface, and water chamber were requested. 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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
continuous positive airway pressure (CPAP) supplies to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 1, 2020, to October 2, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,771.38. The total amount you are being asked to pay is $354.27 ($1,771.38 x 20% = $354.27). An 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 for an injection provided by a participating provider on October 1, 2020, to October 2, 2020.