Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis treatment provided from March 2, 2021, to March 30, 2021.

You asked the Plan to waive the coinsurance for dialysis treatment. You say that dialysis has always been paid 100% and you cannot afford the coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Services to treat kidney disease. 

You have been asked to pay 20% coinsurance for dialysis treatment. Dialysis treatment falls within the Services to treat kidney disease 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 dialysis treatment provided from March 2, 2021, to March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies (95908) provided August 5, 2020.
You asked the Plan to pay for the nerve conduction studies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service billed and does not meet coding standards.
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 95908 is nerve conduction studies, 3-4 studies. We find that CPT code 95908 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of nerve conduction studies, 3-4 studies.
The plan made multiple attempts to obtain the additional records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (95908) provided August 5, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Herceptin Hylecta (J9356).

You asked the Plan to pre-approve Herceptin Hylecta. You say that this is medically necessary. The Plan denied your request. The Plan says that this has not been proven effective.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Herceptin Hylecta. Our reviewer says that the requested use of Herceptin Hylecta is supported in this case. Our physician reviewer found while this use of Herceptin Hylecta is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis, it is supported by clinical research that appears in a CMS-approved medical journal and the documentation supports that it is safe, effective, and otherwise reasonable and necessary for this 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 Herceptin Hylecta have been met. Therefore, we decided that the Plan has to pre-approve Herceptin Hylecta (J9356).

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: Imaging
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram provided on July 2, 2020.

You asked the Plan to pay for the electrocardiogram. You say that the services in dispute were medically necessary. The Plan denied your request. The Plan says that the service in dispute was billed with an invalid diagnosis.

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 pay for the electrocardiogram. Our reviewer says that the electrocardiogram is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has known underlying cardiovascular disease, chronic atrial fibrillation and a cardiac pacemaker. An electrocardiogram to evaluate any changes in her cardiac condition including new rhythm disturbances, the atrial fibrillation rate, new or intercurrent myocardial infarction and the pacemaker function is both reasonable and medically necessary. As the enrollee has known underlying cardiovascular disease and prior rhythm disturbances requiring a pacemaker implant, an electrocardiogram as part of the overall medical evaluation would not be considered for "screening purposes" and is appropriate in this clinical situation. 

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 electrocardiogram have been met. Therefore, we decided that the Plan has to pay for an electrocardiogram provided on July 2, 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an OON provider.

You asked the Plan to pre-approve chiropractic services. You say that you would like approval for these services. The Plan denied your request. The Plan says these services must be provided by a participating provider. The Plan says that there is no network deficiency of participating providers.

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 chiropractic services to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 11, 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 codes 95957, 95909, and 95886 are 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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The definition of code 95909 is nerve conduction studies; 5-6 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).

We find that CPT codes 95957, 95909, and 95886 are not supported in the medical record. Specifically, there is no documentation of digital analysis of an EEG to support code 95957. There is no documentation of 5-6 nerve conduction studies to support code 95909. There is no documentation of needle electromyography to support code 95886. 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 testing services rendered on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (75625, 75710) provided on October 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment.

In this case, the CPT Code Manual definition of code 75625 is "Aortography, abdominal, by serialography, radiological supervision and interpretation". 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 75625 is not supported by the records provided. Our reviewer found that in the procedure coded 75625, the provider performs imaging supervision and interpretation for abdominal aortography with serialography. This is not documented in the Peripheral Angiography/Angioplasty procedure note. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 75625 have not been met. 

Additionally, code 75710 is part of an edit pair with procedure code 37227. Procedure code 37227 is a column one code, and procedure code 75710 is a column two code. Procedure code 37227 has been billed for this date of service, which means that procedure code 75710 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (75625, 75710) provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots (22551) provided on February 26, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.

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 20% coinsurance for surgery performed at an in-network outpatient hospital facility.

You have been asked to pay $2,340.53 (Plan allowed amount of $11,702.63 x 20% coinsurance) for the outpatient surgery provided. 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 the arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots (22551) provided on February 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of blepharoptosis for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found repair of blepharoptosis is considered functional in nature when the upper lid position or overhanging skin is sufficiently low to produce a functional deficit related to visual field impairment or brow fatigue. The margin reflex distance (MRD) should be 2.0 mm or less. The MRD for this enrollee is documented to be 2.25 mm on the right, and 2.5 mm on the left. In addition, color photographs, which are required to support upper eyelid surgery as medically necessary, are not provided. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve repair of blepharoptosis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional inpatient psychiatric treatment.

You asked the Plan to pre-approve additional inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 additional inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 9, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve additional inpatient psychiatric treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an OON provider.

You asked the Plan to pre-approve a second opinion consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 second opinion consultation to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2021.

You asked the Plan to pay for the laboratory services. 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.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental surgery for the enrollee.

You asked the Plan to pre-approve dental surgery. You say that the reasons for treatment are legitimate, medical, not routine and that the patient deserves and demands to be treated. The Plan denied your request. The Plan says that primary dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered by Medicare.

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 dental surgery for the enrollee.
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 member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 patient appears to be improving and is stable but requires additional short-term acute care services to complete treatment which can safely be administered at the current facility. The patient does not require services at the LTACH that are not already available at the current 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro powered arm brace to be provided by an OON provider.

You asked the Plan to pre-approve the MyoPro powered arm brace to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available who can provide a powered upper extremity range of motion device (L8702).

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 MyoPro powered arm brace to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injection provided on March 31, 2021.

You asked the Plan to pay for injection(s); single or multiple trigger point(s), 3 or more muscles (20553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says because of lack of medical documentation they cannot determine whether the services were medically necessary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Medical records supporting medical necessity were requested by the Plan but not received. Based on this information, we decided that Medicare rules for coverage of injection(s); single or multiple trigger point(s), 3 or more muscles (20553) have not been met. Therefore, we decided that the Plan does not have to pay for the trigger point injection provided on March 31, 2021.