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

We decided that the Plan does not have to waive the coinsurance for the stent surgery or the cardiac
catheterization procedure provided from May 8, 2019 to May 30, 2019.
You asked the Plan to waive the coinsurance for the stent surgery and the cardiac catheterization procedure.
You say that you are paying for services that you had no choice in, and you feel that you are being over -
charged. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 each Medicare-covered visit to an out-of-network outpatient facility or ambulatory surgical
center.
You have been asked to pay a total of $3,013.21 for the stent surgery and the cardiac catheterization procedure.
The stent surgery and the cardiac catheterization procedure fall within the "Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. See chart
below.
Dates of Service Service Allowed Amount Coinsurance Member Liability
May 8, 2019 to
May 10, 2019
Stent surgery $9,407.98 20% $1,115.59 - This is
less than the
standard amount
May 28, 2019 to
May 30, 2019
Cardiac
catheterization
$9,488.09 20% $1,897.62
Total $3,013.21
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 stent surgery or the cardiac catheterization procedure
provided from May 8, 2019 to May 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says there are no signs of recurring cancer, or new cancer.The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the specifics of the melanoma are not included in the submitted information as to grade etc. There is a notation describing clear margins at pathology and there are no clinical symptoms or signs suggesting recurrence or metastatic disease. Absent specific reasons for PET imaging there is no medical justification for the exam in the submitted records.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for these 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 did not pre-approve the services 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 physician's services provided on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the chest provided on February 18, 2019.
You asked the Plan to pay for the x-ray. You say that the laboratory told you that they accepted your insurance. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 an x-ray of the chest provided on February 18, 2019.
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 the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee appears to be in the acute phase of illness and needs can be met in the current acute care 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. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and chronic respiratory failure. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo tablets 2MG.
You asked the Plan to pre-approve Livalo tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Livalo tablets are not covered under the enrollee' Medicare Part B benefit. The Plan states they believe the enrollee's pharmacy benefit manager is Silver Scripts.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo tablets 2MG.
Benefits for Livalo tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 25mg.
You asked the Plan to pre-approve the Enbrel. You say that Enbrel is medically necessary. The Plan denied your request. The Plan says coverage for Enbrel is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel 25mg.
Benefits for the Enbrel 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis of the sacroiliac joint (27280).You asked the Plan to pre-approvearthrodesis of the sacroiliac joint. You say that the enrollee has undergone conservative treatment and needs this to relieve her pain.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve arthrodesis of the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show any evidence of sacroiliac joint instability, fracture, or tumor. Therefore, arthrodesis of the sacroiliac is not shown to be needed at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of arthrodesis of the sacroiliac joint have not been met.Therefore, we decided that the Plan does not have to pre-approvearthrodesis of the sacroiliac joint (27280).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the urgent care visit or the Medicare Part B injection provided on July 16, 2019.
You asked the Plan to waive the coinsurance for the urgent care visit and the Medicare Part B injection. You say that your ear was hurting and you went to the doctor, who cleaned it out. You say its better but it is still hurting. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 50% coinsurance for urgently needed services at out-of-network primary care physician's office, specialist's office, or urgent care center and 20% coinsurance for Medicare Part B covered drugs at an out-of-network PCP's office, specialist's office, or pharmacy. You have been asked to pay $38.90 for the urgent care visit and the Medicare Part B injection. The urgent care visit falls within the "Urgently needed services" benefit category. The Medicare Part B injection falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 16, 2019
Urgent care visit
$70.32
50%
$35.16
July 16, 2019
Part B injection
$18.72
20%
$3.74
Total
$38.90
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 urgent care visit or the Medicare Part B injection provided on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveClonidine for the enrollee.You asked the Plan to pre-approveClonidine. You say that this has helped with blood pressure control.The Plan denied your request. The Plan says that self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveClonidine for the enrollee.Benefits for Clonidinemay be available under Medicare Part D.Contactthe 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 preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick (J1438).
You asked the Plan to pre-approve Enbrel Sureclick. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Enbrel Sureclick is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel Sureclick (J1438).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
You asked the Plan to pre-approve bone marrow aspiration. You say that you are appealing the denial of CPT code 20939 for autograft for spine surgery. The Plan denied your request. The Plan says based on a review of peer reviewed literature for the use of bone marrow aspirate in spinal fusions, there is no high-level medical evidence that the use of bone marrow aspirate increases fusion rates in cases such as this enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our physician reviewer found that bone marrow aspirate is not medically necessary at this time. Bone marrow aspirate remains experimental in spinal fusion. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (1851) with suspension sleeve (L2397) provided by prescription connection July 30, 2019You asked the Plan to pay forthe orthoses. You say that that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. There was no evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they arepresented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (1851) with suspension sleeve (L2397) provided by prescription connection July 30, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96413) provided on June 11, 2019.
You asked the Plan to pay for the chemotherapy administration. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not include a start and stop time for chemotherapy administration.
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. 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 chemotherapy administration. Our reviewer says that CPT code 94613 is not supported by the medical record. Our reviewer found the record contains the amount of time for the visit. The duration of the infusion is not documented. The amount of time spent on the infusion services cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413) provided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided on July 12, 2019 to September 6, 2019 by the out of network provider.
You asked the Plan to pay for the office visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 office visits provided on July 12, 2019 to September 6, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 5, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services were not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approve the admission. You say that this is medically necessary for the enrollee to be able to take care of herself upon returning home.The Plandenied your request. The Plansaysneeds can be met in long term care with part-time skilled services in a maintenance program.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that you need daily PT and OT.There are no noted daily skilled complex nursing needs. You recently completed a 2 week SNF stay. While you may benefit from continuing PT and OT, the records do not support the need for ongoing daily skilled therapy.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary. The Plan denied your request. The Plan says the member does not need skilled nursing or skilled therapy on a daily basis and their care can be rendered at a lower level.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in an SNF setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.