Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for psychotherapy (CPT code 90837) provided on January 4, 2021, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the psychotherapy. You say that you do not remember having confirmed the appointment with the provider are seeking reimbursement for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 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 show that you received psychotherapy services on January 4, 2021, from an out-of-network provider. You were asked to pay 40% coinsurance for the services. Your 2021 EOC states that enrollees must pay 40% coinsurance for out-of-network mental health services. 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 psychotherapy (CPT code 90837) provided on January 4, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prochlorperazine 10 mg tablet.
You asked the Plan to pre-approve Prochlorperazine tablet. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have
not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not, as prescribed, among the types which are
covered by Medicare Part B. Specifically, the case record shows that the requested drug is not to be used as a
full therapeutic replacement for an intravenous antiemetic drug that would otherwise be administered at the
time of the chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve
treatment with Prochlorperazine 10 mg tablet.
Benefits for Prochlorperazine tablet 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee February 5, 2019, to
February 24, 2019.
You asked the Plan to pay for the medical services. You say that you believe this is being denied in error. The
Plan denied your request. The Plan says the corrected claims were submitted more than a year after the initial
claim was submitted, therefore does not meet coverage criteria.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service. This also applies for corrected claims.
The record shows that a corrected claim for the medical services was not filed until October 2, 2020. The initial
claim was filed on April 17, 2019. This means that more than one calendar year from the date of service, and
the original billed date had passed before a claim was filed. Therefore, we decided that the Plan does not have
to pay for services provided to the enrollee February 5, 2019, to February 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT code 70553), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says the MRI 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 enrollee did not have any seizure activity for the past year. MRI brain was requested. The enrollee does not require regular MRI surveillance for their epilepsy as the enrollee is only on one (1) medication and has not had seizure activity for one year. Therefore, the MRI will be considered not 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT code 70553), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on February 15, 2021.
You asked the Plan to waive the copayment for the podiatry services. You say that you did not have an office visit within this day. You state you had the foot surgery. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 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 show that you received outpatient surgery on February 15, 2021, and you were seen by the provider after the surgery. Your 2021 EOC states enrollees must pay a $35 copayment for each Medicare-covered podiatry 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 for the podiatry services provided on February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a paravertebral injection (64493) provided on December 28, 2020.
You asked the Plan to waive the copayment for an injection. You say that this service was approved, and you should be reimbursed. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $10 copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers.
You have been asked to pay a $10 copayment for an injection. The EOC confirms that $10 is the required copayment for outpatient surgical services provided in a specialist's office. An injection falls within the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a paravertebral injection (64493) provided on December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on
June 1, 2020.
You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicate that the
services were performed by a physical therapist assistant in a home health or hospice setting. There is a more
appropriate code for the services provided in a home health setting. Based on this information, we decided that
Medicare rules for coverage of code 97110 have not been met. Therefore, we decided that the Plan does not
have to pay for the therapy services represented by code 97110 provided on June 1, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abatacept.
You asked the Plan to pre-approve the Abatacept. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 the Abatacept. Our reviewer says that the Plan requires a trial of drug Remicade, Renflexis or Simponi Aria before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 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 Abatacept have not been met. Therefore, we decided that the Plan does not have to pre-approve Abatacept.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on December 9, 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 services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of major depressive disorder. The case file contains the GeneSight Order Medical Necessity Documentation form, and the results of the testing. The case file does not contain documentation that clearly shows the use of or intent to prescribe a drug that has known drug-gene interactions that requires a PGx test to be ordered to define the safe use of that drug in that patient. The documentation does not support that the testing was 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 pay for the GeneSight testing rendered on December 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laminectomy.
You asked the Plan to pre-approve a laminectomy. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a laminectomy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show severe lumbar spinal stenosis. The enrollee has a history of conservative measures and is elderly with functional impairment. Laminectomy surgery is the care standard for this diagnosis and should be approved. 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 laminectomy have been met. Therefore, we decided that the Plan has to pre-approve a laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the duplex scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the duplex scan. You say that you would like to follow-up with the same provider. The Plan denied your request. The Plan says the provider is out-of-network.
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 a duplex scan to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from February 3, 2021, through February 11, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 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 were admitted on February 3, 2021, and discharged on February 11, 2021. You were asked to pay a $325 copayment per day from February 3, 2021, through February 8, 2021, days 1-6
of your inpatient stay. There were no copayment charges from February 9, 2021, day 7 of your inpatient hospital care until your day of discharge February 11, 2021. Per your contract there is a $325 copayment per day required for days 1-6. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from February 3, 2021, through February 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says your care is routine in nature and the skilled therapists suggest Skilled Nursing Facility care for your needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary to sufficiently treat your wound. The Plan denied your request. The Plan says the rules for SNF care have 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 that based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory molecular pathogen tests (87486, 87581, 87541,
87798, 87640, 87633) provided on July 13, 2020, to September 21, 2020, by an out of network (OON)
provider.
You asked the Plan to pay for respiratory molecular pathogen tests. You say that you visit an assisted living
facility (ALF) every other week to test for COVID-19. You say that you are also asking for a review of the
claims. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 respiratory molecular pathogen tests (87486, 87581, 87541, 87798, 87640, 87633) provided on July 13, 2020, to September 21, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by a neurolytic agent.

You asked the Plan to pre-approve destruction by a neurolytic agent. 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 destruction by a neurolytic agent. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation of the genicular nerves is an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, the request is deemed 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 destruction by a neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by a neurolytic agent.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is
medically stable and is at or near her baseline functionally.

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 services. Our physician reviewer found that the enrollee does not have documented skilled nursing needs. She does not have documented skilled therapy needs. She appears to be functioning at or near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of her condition. Her care needs at this point are custodial. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.