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

We decided that the Plan does not have to waive the co-payment for an observation hospital stay provided from
October 27, 2020, through October 30, 2020.

You asked the Plan to waive the co-payment for the observation hospital stay. You say that you were admitted
inpatient and there should not be a co-payment. The Plan denied your request. The Plan says the correct
co-payment was applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90
co-payment for Emergency Care and Outpatient Hospital Observation.

You have been asked to pay $90 co-payment for the observation hospital stay. The observation hospital stay
falls within the Outpatient Hospital Observation benefit category. There is no additional copay for observation
services. However, you will be responsible for the emergency care or outpatient hospital facility copay if you
visited one of these facilities prior to your observation stay. 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 co-payment
for an observation hospital stay provided from October 27, 2020, through October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis circuit intervention provided on February 26, 2021,
by an out-of-network provider.

You asked the Plan to pay for introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic
angiography of the dialysis circuit (36903). You say that the Plan should pay for this necessary procedure. The
Plan denied your request. The Plan says you did not request prior authorization for the non-urgent 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 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 dialysis circuit intervention provided on February 26, 2021, by an out-of network
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that Zilretta will help with the pain. The Plan denied your
request. The Plan says Zilretta is not recommended for repeated administration. The Plan also says that you
received a Zilretta injection in your right knee on November 4, 2019.
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 Zilretta. Our reviewer says that Zilretta
does not meet coverage criteria. Our physician reviewer found the Food and Drug Administration (FDA) has
not approved Zilretta for repeat knee injection. Our reviewer also found that Zilretta is experimental for repeat
knee injection.
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.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio (J3380).

You asked the Plan to pre-approve Entyvio. You say that the safest option for the enrollee will be
Vedolizumab. The Plan denied your request. The Plan says that this request does not meet the Plan's Part B step
therapy criteria for Entyvio.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that
Entyvio is medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has
not tried and failed the required drugs, Remicade or Inflectra, and Stelara. Our reviewer found that based on the
medical records provided there is concern about the use of Remicade or Inflectra (being tumor necrosis factor
inhibitors) due to a prior breast cancer history. Our physician reviewer also found that the Plan's other required
drug Stelara has a reported malignancy risk of up to 1.7%. Entyvio has a lower reported malignancy risk of
0.4%.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio have been met. Therefore, we decided that the Plan has to pre-approve
Entyvio (J3380).

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 26 skilled nursing visits.

You asked the Plan to pre-approve the skilled nursing visits. You say that you need these visits to be approved for coverage. The Plan denied your request. The Plan says Medicare does not cover skilled nursing for wounds that are considered small or superficial.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 skilled nursing visits. Our reviewer says that you do not need ongoing professional skilled nursing visits for your condition. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that your wound care is not complex. Our physician reviewer also found that you have had extensive prior skilled nursing for this condition with skin care education. 

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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 26 skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), mandibular partial denture (D5214), five removals of residual tooth roots (D7250 x5), and surgical extraction (D7210).

You asked the Plan to pre-approve the maxillary partial denture, mandibular partial denture, removals of residual tooth roots, and surgical extraction. You say that you need these services. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), mandibular partial denture (D5214), five removals of residual tooth roots (D7250 x5), and surgical extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the audio-only evaluation and management (EM) visit provided on January 27, 2021 billed with code 99214-UD.

You asked the Plan to pay for the audio-only EM visit. You say that Arizona Medicaid pays for telephone-only visits through the usual EM code with modifier -UD. It also requires the place of service code for home, which is 12. This was billed correctly and should be paid. The Plan denied your request. The Plan says this was billed with the incorrect POS code.

The Plan must follow Medicare rules. Medicare rules say that providers must bill for services using the code that fully describes the services rendered. For audio-visual telehealth visits, Medicare requires providers to bill the standard EM code with modifier -95 and using the POS code that would be used if the visit were performed in-person. In addition, Medicare has three CPT codes specifically for telephone audio-only visits, 99441, 99442, and 99443.

Based on this information, we find that using the code 99214 with a -UD modifier is not valid for Medicare billing of an audio-only EM visit. Therefore, we decided that the Plan does not have to pay for the audio-only evaluation and management (EM) visit provided on January 27, 2021 billed with code 99214-UD.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept intraosseous nerve ablation procedure.

You asked the Plan to pre-approve the requested services. You say that the procedure is designed to address chronic low back pain. The Plan denied your request. The Plan says medical studies have not demonstrated the requested procedure is as effective or superior to options covered by Medicare.

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 has chronic axial low back pain. She has tried Hydrocodone, Gabapentin and Tizanidine for pain. She has had 5 epidural steroid injections as well as facet joint RFA, but the pain continues. The requested procedure is considered experimental/investigational because of the limited data supporting its use. Therefore, the request 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-approve an intracept intraosseous nerve ablation procedure.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for ambulance services (A0427, A0425) provided on February 1, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you reached your annual maximum out-of-pocket level prior to the bill at issue. The Plan denied your request. The Plan says that the correct copayment was applied.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We requested documentation in support of the Plan's assertion that you have not reached your annual maximum out-of-pocket. The Plan did not provide a response to our request within the timeframe required for review of this case. Therefore, we decided that the Plan has to waive the copayment for ambulance services (A0427, A0425) provided on February 1, 2020.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the MRI provided on January 27, 2021.

You asked the Plan to waive the co-payment for the MRI's. You say that you had been suffering from neck for months, the pain came back after physical therapy and an MRI was ordered. You say that you followed the request given by the doctor, you followed all the home exercise requests given and all the guidelines to improve your health and well being. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment for diagnostic radiology other than CT scans from an in-network provider.

You have been asked to pay $219.35, which is less than the standard $250 co-payment for the MRI's. The MRI's fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the MRI provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667 LT, RT) provided September 21, 2020.

You asked the Plan to pay for pneumatic compression device and appliance. You say that you have attached all the supporting documentation, please reprocess the claim. The Plan denied your request. The Plan says the available medical records do not support necessity of the medical equipment as defined by Medicare criteria.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

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 pneumatic compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the Medicare criteria listed for the requested pneumatic compression device (E0651) and segmental pneumatic appliance (E0667 LT, RT).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667 LT, RT) provided September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections (G0260).

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are covered when 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 injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found there is no documentation of physical exam tests such as Thigh Thrust test, Sacral Compression and Distraction tests, and Gaenslen's test. Without these tests being performed and documented, medical necessity cannot be established.

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections (G0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from December 24, 2020, to December 30, 2020.

You asked the Plan to waive the copay for the services provided. You say that you only stayed in the hospital because of the virus. The Plan denied your request. The Plan says the copay was applied appropriately.

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 $250 copay per day for days 1-7 for inpatient hospital care. 

You have been asked to pay a $250 copay per day for the inpatient services provided. The services fall 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 copay for the inpatient hospital services provided from December 24, 2020, to December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says this request is not covered under the medical benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Prolia.

Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the needed care in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with a gastrointestinal bleed and developed acute kidney injury and respiratory failure form pneumonia requiring mechanical ventilation. At this time, he continues to receive acute critical care services and those have not been denied. The record does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.