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

We decided that the Plan does not have to pay for outpatient services (78452, G0463, 93306, A9502) provided on March 12, 2021.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-approved. There were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient services (78452, G0463, 93306, A9502) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received March 23, 2021.

You asked the Plan to pay for the limited oral evaluation - problem focused. You say that your notice of denial refers to the wrong tooth. The Plan denied your request. The Plan says this service is limited to one procedure per plan year.

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 is only covered one procedure per year. The Plan has submitted evidence that you last received this service on March 18, 2021. When you received this service on March 23, 2021 your benefit was exhausted.

Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the neurostimulator insertion provided on June 18, 2019.
You asked the Plan to waive the cost for the neurostimulator insertion. You say that you were not told the hospital was not in-network and you were not informed you would have to pay such a large bill. You say that the doctor said you needed to do this, and it isn't your fault if it isn't covered. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan clearly says that after you pay your $750 deductible, you pay 40% coinsurance for Medicare-covered outpatient surgery from an out-of-network provider. The item or service you asked the Plan to waive the cost for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the neurostimulator insertion was received on June 18, 2019. Therefore, $449.56 was been applied to meet the deductible.
Since the $750 deductible was met you have also been asked to pay $8,101.79, which is less than the standard 40% coinsurance for the neurostimulator insertion. 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 cost for the neurostimulator insertion provided on June 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95999, 95955, 95910, 95886, and
95887) provided July 14, 2020.

You asked the Plan to pay for the neuromonitoring services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 codes 95999, 95955, 95910, 95886, and 95887 are not supported in the medical record.
Specifically, the Technical Report provided does not sufficiently support the CPT codes billed. Train-of-four
testing is inclusive to intraoperative neurophysiological monitoring and is not separately payable. Based on this
information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met.

Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95999, 95955, 95910, 95886, and 95887) provided July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided on September 15, 2020.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says this service was out-of-network and was not emergent or pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81479) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on July 21, 2020.
You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that the services rendered were performed by an occupational therapist assistant in the home health or hospice setting. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stellate ganglion block.
You asked the Plan to pre-approve the requested services. You say that the injection is the only thing that eases your pain. The Plan denied your request. The Plan says there is no clinical effectiveness for a third block with no improvement from the prior 2.
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 requested services. Our physician reviewer found that you have pain in her left index finger and burning pain/numbness in fingers 3,4,5. You have had peripheral nerve blocks which produced 80% pain relief. You have tried physical therapy, Lidocaine and CBD oil. You have had 2 left stellate ganglion nerve blocks without pain relief. This request is for a 3rd stellate ganglion block. You do not have sympathetically maintained pain. Two stellate ganglion blocks have not produced significant pain relief. The request for a third stellate ganglion block 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a stellate ganglion block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.

You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 88321) provided to the enrollee on November 13, 2020.

You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your request. The Plan says the allowable units for this code are one.

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 88321 is "Consultation and report on referred slides prepared elsewhere (if appropriate)." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 88321 has a MAI indicator of "2" and only allows 1 unit per day. Because 2 units total for November 3, 2020 was billed to the health plan, the Medicare guideline for MUE billing for 88321 has been exceeded and 88321 (2 units) is not eligible for reimbursement consideration.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (CPT 88321) provided to the enrollee on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve precision attachments (D5862) for teeth # 20, 24, 25, and 28, and surgical placement of miniature implants (D6013) for teeth # 20, 24, 25, and 28.
You asked the Plan to pre-approve the dental services. You say that you do not have proper teeth in your mouth to chew your food due to medical issues. You say that you have been losing an excessive amount of weight. You say that your bottom denture is causing you pain. You also need the dentures to be remade immediately to help you eat. The Plan denied your request. The Plan says precision attachments are not listed as covered services. The Plan says that surgical placement of miniature implants are not listed as covered services either.
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 pre-approve precision attachments (D5862) for teeth # 20, 24, 25, and 28, and surgical placement of miniature implants (D6013) for teeth # 20, 24, 25, and 28.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (74177) provided April 8, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 20% coinsurance for diagnostic radiology. You have been asked to pay a 20% coinsurance for the CT scan. The CT scan falls within the diagnostic radiology 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 a computed tomography (CT) scan (74177) provided April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 22, 2021, to February 18, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were covered during the dates in question and do not believe you owe a cost share. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $225 copayment per day, days 1 to 7 and a $0 copayment per day, days 8 to 90 for inpatient hospital care. You have been asked to pay a total cost share of $1575 for the inpatient hospital care ($225 copayment x 7 days). This service 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 inpatient hospital care provided January 22, 2021, to February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you do not have any strength to pull yourself up, walk with a walker, have to be guided, and cannot sit on the toilet. You say that your providers believe you have inflammation in your muscles. You say that you need physical therapy and the Plan's denial is a death sentence for you. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia and weakness. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 Keytruda. Our reviewer says that the medication is medically necessary. Our physician reviewer found Pembrolizumab is FDA approved for the treatment of cervical cancer. Vulvar cancer is treated like cervical cancer. There is not stated duration of therapy and although some experts may stop after 2 years many will continue until toxicity or progression. The service is reasonable and 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the cervical spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says the enrollee has not failed standard conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI. Our physician reviewer found that the enrollee has neck and right shoulder pain. X-rays revealed degenerative changes of both the right shoulder and cervical spine. She has had a course of acupuncture with temporary relief of her symptoms. She has no neurological deficit to represent a red flag such that immediate MRI without a course of PT is necessary. In addition, as she has both right shoulder and cervical spine pain perhaps a course of PT can pinpoint the source of her discomfort. Therefore, the requested MRI 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and ultrasounds (99203, 76830, 76856, 81002) provided January 14, 2021.

You asked the Plan to waive the copayment for the office visit and ultrasounds. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 $45 copayment for specialist visits and a $110 copayment for diagnostic radiology. 

You have been asked to pay a $45 copayment for an office visit and a $110 copayment for the ultrasounds. The office visit falls within the specialist visits benefit category, and the ultrasounds fall within the diagnostic radiology 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 office visit and ultrasounds (99203, 76830, 76856, 81002) provided January 14, 2021.