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

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there are in-network providers that can render the 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 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 the medical services to be provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sacroiliac joint injection.You asked the Plan to pre-approvethe requested services. You say that you are in pain.The Plan denied your request. The Plan says additional injections would not be medically appropriate.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 chronic low back pain, and have received 4 sacroiliac (SI) joints this year. This request exceeds utilization criteria which limits SI joint injections to 4 in arolling 12-month period.  Therefore, the requested procedure is considered 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-approvea sacroiliac joint injection
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on December 4, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you did not receive the device. 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 20%
coinsurance for DME and related supplies.
The record shows that you received DME on December 4, 2019. Therefore, you are responsible to pay your
share of the cost-sharing charges. The allowed amount is $499 and 20% of that is $98.80.
You have been asked to pay the total coinsurance amount of $98.80 for DME. DME falls within the DME and
related 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 coinsurance for DME provided on
December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forvision care and ophthalmic diagnostic imaging provided on May 19, 2020.You asked the Plan to waive the copayments forvision care and ophthalmic diagnostic imaging. You say that the services were medically necessary.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 $35 copayment for vision care. Your contract with the Plan also clearly says that you must pay an $85 copayment for diagnostic procedures and tests.You received vision care on May 19, 2020. Therefore, you are responsible to pay the $35 copayment. You received ophthalmic diagnostic imaging on May 19, 2020. Therefore, you are responsible to pay the allowed amount of $37.15, which is less than the $85 copayment. The total amount you owe is: $72.15.  You have been asked to pay the total amount of $72.15 for vision care and ophthalmic diagnostic imaging. Vision care falls within the vision care benefit category. Ophthalmic diagnostic imaging 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 copayments forvision care and ophthalmic diagnostic imaging provided on May 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveMRI, any joint of lower extremity; without contrast material (CPT Code 73721).You asked the Plan to pre-approvethe MRI. You say that the service is necessary.The Plan denied your request. The Plan says that the service is not necessary.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 the MRI. Our physician reviewer found the hip pain is indication for MRI as plain films have limited diagnostic capability for hip pain.  Our physician reviewer feels that the MRI indicated and 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 MRI have been met.Therefore, we decided that the Plan has to pre-approveMRI, any joint of lower extremity; without contrast material (CPT Code 73721).If the Plan does not agree withour 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COLARIS myRisk testing.

You asked the Plan to pre-approve these services. You say that the testing is in the enrollee's best interest. The
Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that genetic testing for Lynch syndrome is 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee was found to have 31
polyps, 28 of which were adenomas, during a recent colonoscopy. The enrollee does not have a personal
history of colon cancer, and the family history is not documented in the case file. The testing is 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 COLARIS myRisk testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided by Gadsden Foot Clinic on October
23, 2019.
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a
covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by Gadsden
Foot Clinic on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not identified as widely used and generally accepted for the proposed use.

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 the enrollee presents with a history of chronic low back pain radiating to the lateral right lower extremity with dysesthesias. Signs and symptoms have been reported consistent with neurogenic claudication. She has failed to achieve adequate improvement with greater than 6 months of reasonable and/or comprehensive conservative treatment, including medications, epidural steroid injection, and a spinal cord stimulator. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the standard lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Additionally, the safety and effectiveness of the interspinous spacer has not been studied in those with prior lumbar spine surgery, which includes the requested surgical level of L2/3. The requested service would not be considered the standard of care for the enrollee's medical condition. Therefore, this request is not safe and effective or medically reasonable and necessary for treatment of this enrollee's medical condition.

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 an interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require close medical supervision.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 physician reviewer found that you were admitted to the acute hospital for surgical treatment of lung cancer. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services provided on June 22, 2020.

You asked the Plan to waive this copayment. You say that your doctor insisted you go to the emergency room and you do not believe you should be responsible for the copayment. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 $90 copayment for emergency room services. 

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 $90 copayment charged for emergency room services provided on June 22, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the services rendered were medically necessary and cost-saving. The Plan denied your request. The Plan says this care was not approved in compliance with the Plan's authorization procedure.

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 has network providers available who can provide 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 medical services provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.

You asked the Plan to pre-approve these services. You say that the enrollee has bronchiectasis exacerbations.
The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has bronchiectasis that is
difficult to evaluate and manage due to baseline compromise and various complications that can arise from not
clearing the lungs with excessive secretions. The CT scan is integral in evaluation of patients with
bronchiectasis due to difficulty in assessing symptoms and need to follow the condition. The services are
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 these services have been met. Therefore, we decided that the Plan has to preapprove
a computed tomography (CT) scan of the chest.

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 endovenous ablation therapy of additional veins (36476-51)
provided on March 12, 2020.

You asked the Plan to pay for endovenous ablation therapy. You say that this was billed correctly. The Plan
denied your request. The Plan says modifier 51 is not appropriate for this service.

The Plan must follow Medicare rules. Medicare rules say that if Field 21 for any of the multiple procedures
contains an indicator of "0," the multiple surgery rules do not apply to that procedure.

We looked at the file and Medicare rules. CPT code 36476 has a multiple surgery indicator (Field 21) of 0,
meaning multiple surgery rules do not apply and it is not appropriate to bill modifier 51. Based on this
information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met.
Therefore, we decided that the Plan does not have to pay for endovenous ablation therapy of additional veins
(36476-51) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose and somatomedin testing provided on May 5,
2020.

You asked the Plan to pay for lab tests. You say that the order for these tests are included in the chart notes.
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the
documentation submitted does not include a valid physician order, lab requisition, or medical records to
support these specific tests.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order these specific lab services. Based on this information, we decided that Medicare rules for
coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for blood
glucose and somatomedin testing provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe oncology visit you had .You asked the Plan to waive the copayment forthe oncology visit. You say that this was a telehealth visit, so no copayment should apply.The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that they contacted the provider and they confirmed that this was an in-person visit.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. 

You have been asked to pay a $45 copayment for the oncology visit. 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 forthe oncology visit you had.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (92222) provided on January 27, 2020.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the member was seen multiple times on the same date of service. The Plan denied your request. The Plan says this is a duplicate claim

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. 

In this case, the CPT Code Manual definition of code 92222 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 92222 is not supported in the record. Specifically, the record indicates that another evaluation and management code, CPT 92223, has been approved and paid to the same provider for the same date of service. The record does not indicate that initial hospital services were rendered multiple times on the same date of service and there is no modifier to indicate that the member was seen for unrelated problems. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (92222) provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 8, 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 screening tests are 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 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 May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided.

You asked the Plan to pay forthe chiropractic services. You say that the services should be covered.The Plan denied your request. The Plan says devices are not covered under the chiropractic benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. T

he records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided.