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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 24, 2020, to August 24, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were admitted due to COVID-19 and thought that copayments were waived. 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 a $295 copayment per day for days 1-6 for inpatient hospital care. You received an inpatient hospital stay from July 24, 2020, to August 24, 2020. Inpatient hospital stays are still subject to cost-sharing charges even with a COVID-19 diagnosis. Therefore, you are responsible to pay $740, which is less than the total copayment amount. You have been asked to pay $740 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay from July 24, 2020, to August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on October 29, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says this laboratory is not contracted with 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 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 laboratory services provided by an out-of-network provider on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an out of network (OON) provider.
You asked the Plan to pay for the dental services. You say that the provider is in network. The Plan denied your request. The Plan says the provider is not in network, and criteria for obtaining out of network coverage was not met.
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 dental services provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services (99328) provided on October 31, 2020.
You asked the Plan to pay for the emergency room services. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says this claim did not include an appropriate primary, first listed or principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We find that CPT code 99284 is not supported in the record. Specifically, diagnosis code R65.10 has a code first note, meaning that the underlying condition must be sequenced first. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services (99328) provided on October 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided September 29, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to see a new provider because your previous dentist was no longer in-network. The Plan denied your request. The Plan says you have exceeded the frequency limit for the service and therefore it is not covered.
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 case file confirms that the Plan has already covered one comprehensive oral evaluation in the past three years. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, the lesion removals, and the pathology service provided on November 4, 2020 to November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit, lesion removals, and the pathology service. You say that you have seen this doctor before. You say you were told this doctor was in-network. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract.
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. The record shows there were no visits with this provider prior to these services. Therefore, we decided that the Plan does not have to pay for an office visit, lesion removals, and a pathology service provided on November 4, 2020 to November 17, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral epidural steroid injections provided on August 26, 2020.
You asked the Plan to pay for the bilateral epidural steroid injections. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64483 is 1. You billed a total of 2 units of this code, exceeding the MUE. This code also has a bilateral surgery indicator of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) to be considered for payment. Based on this information, we decided that Medicare rules for coverage of the bilateral epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral epidural steroid injections provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-rays provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 office visit and x-rays provided on November 10, 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 genicular nerve radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have
osteoarthritis of the right knee. The requested genicular RFA is considered experimental/investigational in
nature and is the subject of ongoing clinical trials. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve radiofrequency ablation (RFA).

Local Coverage Article A56687 and Local Coverage Determination L36471 used by the Plan are not binding
for the services at issue and were not used in the Maximus determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply for a therapeutic CGM (K0553) provided on September 5, 2020.
You asked the Plan to pay for a supply for a CGM. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The medical documentation in the case record does not support that the enrollee has a diagnosis of diabetes. Based on this information, we decided that Medicare rules for coverage of a supply for a CGM have not been met. Therefore, we decided that the Plan does not have to pay for a supply for a therapeutic CGM (K0553) provided on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteogenic bone stimulator provided on June 17, 2020.
You asked the Plan to pay for the osteogenic bone stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the device rendered was not medically necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 osteogenic bone stimulator. Our reviewer says that the documentation does not support that the device rendered was medically reasonable or necessary. Our physician reviewer found the enrollee was being treated for right 5th metatarsal fracture with nonunion. Detailed documentation is not evident regarding serial x-rays over at least 90 days to support classification of nonunion (the lack of any evidence of advancing healing on serial x-rays over 90 days). Such bone stimulators are not typically supported for foot outside of treatment for nonunion, which had not been demonstrated at the time. There is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of this request as an exception. Therefore, the enrollee did not meet criteria for the requested device. 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 osteogenic bone stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the osteogenic bone stimulator provided on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the referring provider is out-of-network.
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 lab work provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure Plus nutritional supplement.

You asked the Plan to pre-approve Ensure Plus. You say that the member has difficulty swallowing and needs this supplement. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve Ensure Plus nutritional supplement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks. You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested medial branch blocks. 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 medial branch blocks. Our reviewer says that the enrollee does not meet criteria for the requested medial branch blocks. Our physician reviewer found the enrollee has chronic low back pain. He takes ultram and gabapentin for pain. He had an Epidural steroid injection which gave him 20% pain relief and a set of diagnostic MBBs which gave him zero relief. The request is for another set of MBBs. The enrollee did not achieve 80% pain relief from the first set of MBBs. It is not necessary to repeat a negative block. The request 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 medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 16, 2020, through November 18, 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 from September 16, 2020, through November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift chair and lift chair motor.
You asked the Plan to pre-approve a lift chair and lift chair motor. 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.
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. As for the seat lift mechanism, or lift chair motor, Medicare criteria are not met as the enrollee must be able to walk once standing. The file shows that the enrollee is bed bound. Based on this information, we decided that Medicare rules for coverage of a lift chair and lift chair motor have not been met. Therefore, we decided that the Plan does not have to pre-approve a lift chair and lift chair motor.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Procrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for you. In addition, the documentation does not support that your iron deficiency has been adequately 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is status post SI joint injections. She reports significant relief of her axial back pain. She has multiple levels of significant spinal stenosis most significant L2-L3 and L3-L4. The Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device. Open laminectomy is the gold standard for treatment of spinal stenosis.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on October 5, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges because the laboratory tests were part of an annual wellness exam. 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 a $50 copayment for lab services provided at an outpatient hospital facility. You received laboratory tests on October 5, 2020, at an outpatient hospital facility. Laboratory tests are not included in annual wellness exams. Therefore, you are responsible to pay the allowed amount of $31.57, which is less than the $50 copayment. You have been asked to pay $31.57 for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory tests provided on October 5, 2020.