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

We decided that the Plan does not have to pre-approve knee surgery.

You asked the Plan to pre-approve knee surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found arthroscopy for advanced arthritis is not supported in the peer review literature. It does not positively affect outcomes and it is not medically needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee surgery.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on
September 28, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 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 a domiciliary, rest home visit provided on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Visual Evoked Potential (VEP) provided on November 4, 2020.
You asked the Plan to pay for VEP, checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report (95930). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the clinical value and effectiveness of Visual Evoked potential in the setting of open angle glaucoma have not been demonstrated in the peer-reviewed literature.
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 VEP, checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report (95930). Our reviewer says that the test is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate why the requested test was performed. CPT code 95930 excludes glaucoma testing. Therefore, the documentation does not support the medical reasonableness and necessity of the service. The service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of VEP, checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report (95930) have not been met. Therefore, we decided that the Plan does not have to pay for Visual Evoked Potential (VEP) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on December 11, 2020.

You asked the Plan to waive the copayment for specialist services. You say that this copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $50 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2020.
You asked the Plan to pay for the laboratory 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 payable.
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 the laboratory services are not supported in the medical record. Specifically, these services should be coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services rendered from September 29, 2020 to October 12, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 you must pay a $25 copayment for each Medicare-covered physical, occupational, or speech language therapy visit.
Review of the file shows that you received four PT sessions from September 29, 2020 to October 12, 2020. You have been asked to pay a $25 copayment per date of service for these services, for a total of $100. These services fall within the Medicare-covered physical, occupational, or speech language therapy visit 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 the physical therapy (PT) services rendered from September 29, 2020 to October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 29, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says there is no history of an office visit conducted to show the ordering provider could have diagnosed or treated the member for any issues requiring the orthoses.
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 orthosis (L1833) and suspension sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an appropriate evaluation of the enrollee, 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 orthosis (L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 29, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a pacemaker.
You asked the Plan to pre-approve a pacemaker. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber cardiac pacemakers are covered when specific criteria 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 a pacemaker. Our reviewer says that the services are medically necessary. Our physician reviewer found based on the enrollee's clinical condition and the symptomatic sinus bradycardia, she meets coverage criteria for the pacemaker placement. 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 pacemaker have been met. Therefore, we decided that the Plan has to pre-approve a pacemaker.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 8, 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 prior authorization was not obtained by the member's primary care physician. 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 September 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider from October 29, 2020, to November 13, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these
charges. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295
copayment for outpatient surgery/in-network/outpatient hospital.
You have been asked to pay a $295 copayment for an outpatient surgery. An outpatient surgery 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 from October 29, 2020, to November
13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81210, 81275, 81401, 81311) provided August 18, 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 Medicare does not allow separate payment for multiple tests for the same analyte.
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, we have confirmed that the codes billed share column one/ column two relationships and cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81210, 81275, 81401, 81311) provided August 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing care (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level given your weight bearing limitations does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing care (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay more for the CT scan provided on December 3, 2020.
You asked the Plan to pay for the CT scan. You say that the claim should be processed, and the $180 copayment should be accepted. The Plan denied your request. The Plan says the copayment 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 you must pay a $180 copayment for advanced imaging services at an in-network PCP's office, specialist's office or freestanding radiological facility. You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the claim processed and applied the $180 copayment. 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 pay more for the CT scan provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injections.

You asked the Plan to pre-approve Zilretta. You say that you are requesting an injection in your left knee, but the previous injection was in your right knee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the safety and efficacy of repeat administration of Zilretta has not been established.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 you do not meet the Medicare criteria for the requested use of Zilretta. Our physician reviewer found repeat injection of Zilretta has not been approved by the Food & Drug Administration (FDA). Even though this request is for your other knee, the effects of multiple Zilretta injections in the same individual have not been described. 

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 Zilretta injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on June 24, 2020.
You asked the Plan to waive the deductible for lab work. You say that you do not know why you are being charged this because you already paid your deductible. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for out-of-network services. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/out-of-network/labs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests/out-of-network/labs. This cost sharing is a contractual obligation that had not been met at the time lab work was received on June 24, 2020. The total amount you are being asked to pay is $71.62. Therefore, we decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crowns (D6750) for teeth # 24 and 25, and the pontic (D6240) for tooth # 25.
You asked the Plan to pre-approve the fixed bridge. You say that the top bridge was approved but the bottom one was not. You say that your posterior bridge makes you nauseous. You say that you would like the current authorization to be reversed and to authorize the lower fixed bridge and deny the upper fixed bridge. You also say that the lower fixed bridge is more urgent. The Plan denied your request. The Plan says the closure of gaps (diastemas) between teeth is not considered a medically necessary treatment.
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 the retainer crowns (D6750) for teeth # 24 and 25, and the pontic (D6240) for tooth # 25.