Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeight (8)additionalPT visits.You asked the Plan to pre-approveeight (8) additional PT visits. You say thatyou need the continuing therapy because it is helping you, but your shoulder is not functioning up to par like it needs to be and the healing process istaking longer than you thought it would. You say that you arecommitted to getting back to 100% useofyour right shoulder and you would appreciate the consideration for coverage of the additional PT.The Plan denied your request. The Plan says there has been no sustainable measurable improvement in the shoulder level of function with the physical therapy services to date.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 pre-approve eight (8) additional PT 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 that based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records you appear to have improved with therapy after 27 treatment sessions and have improved strength and tolerance to posterior shoulder exercises. Further utilization of the home exercise program appears appropriate at this point.There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist.There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approveeight (8) additional PT visits.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric evaluations, positive airway device supplies and
laboratory services provided from June 1, 2020 to August 19, 2020.
You asked the Plan to pay for psychiatric evaluations, positive airway device supplies and laboratory services.
You say that the Plan should pay the claims. The Plan denied your request. The Plan says secondary payments
cannot be considered without the identity of or payment information from the primary payer. The information
was either not reported or was illegible. The respiratory equipment will not be paid because the provider is not
contracted with Medicare and there is no evidence of payment for the laboratory services.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested information but not received it. As the secondary insurer, the Plan cannot be held responsible for psychiatric evaluations, positive airway device supplies and laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for psychiatric evaluations, positive airway device supplies and laboratory services provided from June 1, 2020 to August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on September 25, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you verified that you would not owe any copayments due to COVID-19 and disagree with the charges. 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 $14 copayment for X-rays. You received an X-ray on September 25, 2020. X-rays are not included in the COVID-19 waiver. Therefore, you are responsible to pay the $14 copayment.
You have been asked to pay a $14 copayment for an X-ray. An X-ray falls 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 an X-ray provided on September 25, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member would be well suited in an inpatient rehabilitation facility in order to regain strength to reach prior level of function. The Plan denied your request. The Plan says that the enrollee does not need close supervision by a rehabilitation doctor with face to face visits three times per week.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia and respiratory failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on May 31 to June 3, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would find it very difficult to pay because your income is very limited. 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 $295 copayment for each Medicare-covered day for days 1 to 5 for each inpatient hospitalization. You have been asked to pay $885, or a $295 copayment for each day for a 3-day 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 on May 31 to June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and hip x-ray provided on January 25, 2021.
You asked the Plan to waive the copayment for the office visit and hip x-ray. You say that you have a $40 copayment for specialty visits, but you received a bill for $75. The Plan denied your request. The Plan says the copayments 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules) and a $35 copayment for each Medicare-covered standard x-ray service. You have been asked to pay a $40 copayment for the office visit and a $35 copayment for the hip x-ray. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The hip x-ray falls 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 the office visit and hip x-ray provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the Part B drug services (J7999) provided on February 24, 2021.
You asked the Plan to waive or reduce the coinsurance for the drug services. You say that this bill is more than two times the cost of your last treatment. The Plan denied your request. The Plan says they have agreed to waive the cost sharing for some of the services provided; however, Part B drugs require 20% coinsurance.
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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $150 for the drug services. The total cost for this service is $750 ($750 x 20% coinsurance = $150). 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 or reduce the coinsurance for the Part B drug services (J7999) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced care planning rendered on June 20, 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 procedure code 99497 is not supported.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of a discussion between the provider and patient regarding eventual end-of-life decisions. 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 pay for the advanced care planning rendered on June 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement calf/rest pads (E0995) for a power wheelchair.
You asked the Plan to pre-approve replacement calf/rest pads (E0995). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. rules say that replacement calf/rest pads are included in a Group 3 PWC described by code K0857. Review of the file shows that the Plan approved the requested Group 3 PWC and all requested accessories except for the replacement calf/rest pads. The replacement calf/rest pads are already included in the approved Group 3 PWC and therefore do not need to be approved separately. Therefore, we decided that the Plan does not have to pre-approve replacement calf/rest pads (E0995) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99213) provided to the enrollee on February 24, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services to the enrollee as outlined on the enrollee's identification card.
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 services (CPT code 99213) provided to the enrollee on February 24, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device.
You asked the Plan to pre-approve the MyoPro device. You say that this would be helpful to assist the enrollee with daily living activities. The Plan denied your request. The Plan says this device is currently considered experimental.
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 MyoPro device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 39-year-old woman who has spastic left hemiparesis following resection of a oligodendroglioma from the right hemisphere. The clinical documentation by the ordering physician does not support that the requested orthotic device is an accepted standard of medical practice that meets but does not exceed the enrollee's medical need and does not indicate that the device is at least as beneficial as existing and available medically appropriate alternatives. 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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) and tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) provided on December 30, 2020.
You asked the Plan to pay for the medical services. You say that you requested an appointment with your family medicine unit where in the past, you had been charged $5 copayments. You state for this date of service you were assigned a specialist without prior notification. You state this was not an emergency visit and you were advised there would be no additional costs for the vaccine you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received the office services and a tetanus vaccine. You were asked to pay a $5 copayment for the office visit. Furthermore, the vaccine is not covered because the rules say that immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation is not covered. 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 for the office visit (CPT code 99213) and tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) provided on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided from August 20, 2020, to December 24, 2020.You asked the Plan to waive the copayments forspecialist visits. You say that you received a notice that all copayments would be waived due to COVID-19 and you cannot afford the charges.The Plan denied your request. The Plan says theclaims 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 $30 copayment for specialist visits.You received specialist visits from August 20, 2020, to December 24, 2020, for a total of 12 visits. Specialist visits are not included in the COVID-19 waiver. Therefore, youare responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 (copayment) x 12 (specialist visits) = $360.  You have been asked to pay the total copayment amount of $360 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 youenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forspecialist visits provided from August 20, 2020, to December 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve bone marrow aspiration (20939). You say that the requested bone marrow aspiration (20939) is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration (20939) 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 bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration (20939) is not medically necessary. Our physician reviewer found the plan approved outpatient ACDF C4-C7 with removal of anterior plate. Bone marrow aspiration remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of bone marrow aspirate for use as bone graft.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs).

You asked the Plan to pre-approve RFAs. You say that your physician told you that you need to have this done.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not have localized pain in your back and the records do not show that you received at least 80% pain relief from your previous injections.

The Plan follows Medicare rules. Medicare rules state that radio frequency ablations are only covered under certain conditions.

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 RFAs. Our reviewer says that you do not meet the Medicare criteria for the requested radio frequency ablations. Our physician reviewer found the translatability of intra-articular (IA) injections to medial branch blocks (MBBs) is controversial and practice guidelines do not address the use of IA injections as a means to determine radiofrequency ablation (RFA) utility. You have received IA facet joint injections, not MBBs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFAs have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs).