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

We decided that the Plan does not have to waive the copayment for the ultrasound you received on July 17, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you thought copayments were waived when you had this service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the ultrasound ($66.53) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan says that in relation to the copayment waiver, copayments during this period were only waived for certain services. Copayments were not waived for diagnostic imaging services unrelated to the Coronavirus.

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 $150 copayment for radiological diagnostic services, not including x-rays.

You have been asked to pay a $150 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic services, not including x-rays, 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 the ultrasound you received on July 17, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve gastric bypass surgery and hiatal hernia repair.

You asked the Plan to pre-approve gastric bypass surgery and hiatal hernia repair. You say that the requested gastric bypass surgery and hiatal hernia repair are medically necessary. The Plan denied your request. The Plan says that the requested gastric bypass surgery and hiatal hernia repair are not medically necessary.

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 gastric bypass surgery and hiatal hernia repair. Our reviewer says that the requested gastric bypass surgery and hiatal hernia repair are medically necessary. Our physician reviewer found the record indicates that the enrollee has a body mass index of 45. The record indicates that the enrollee is H. pylori negative. The record indicates that the enrollee has been appropriately evaluated. The requested procedure is medically necessary and reasonable, as defined by Medicare rules, for the enrollee's condition. The elements of the coverage criteria are satisfied. The requested procedure is recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastric bypass surgery and hiatal hernia repair have been met. Therefore, we decided that the Plan has to pre-approve gastric bypass surgery and hiatal hernia repair.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic office visits and treatment to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON orthopedic office visits and treatment. You say that the provider you are requesting has experience and expertise in the services you need. The Plan denied your request. The Plan says these services are available in-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 orthopedic office visits and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted evaluation and management services (99499) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the evaluation and management services. You say that you are trying to get updated authorization for this year. You would like this for continuity of care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 unlisted evaluation and management services (99499) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99152 provided on September 10, 2020.

You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99152.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not contain evidence that moderate sedation was performed with the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99152 provided on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.

You asked the Plan to pre-approve the continued care. The Plan denied your request. The Plan says this is not medically necessary.

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 the continued care. Our reviewer says that the requested inpatient mental health services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not require inpatient mental health treatment beyond the dates in question as he is not a danger to himself or others and does not have any auditory or visual hallucinations or behavioral issues. It does not appear that active treatment is taking place beyond the date in question. It does not appear that the services are reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.

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 continued care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are 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 health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not document that the clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. The criteria are not met and therefore the Euflexxa is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroplasty to be provided at an out-of-network
facility.

You asked the Plan to pre-approve arthroplasty, knee, condyle and plateau; medial OR lateral compartment
(27446). You say that you have been trained and certified to perform this procedure with robotic assist. The
Plan denied your request. The Plan says they have in-network providers who can provide this service.

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 facility in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve knee
arthroplasty to be provided at an out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99443), the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), and the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359) rendered by the out-of-network (OON) provider on February 19, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered 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 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 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 the telephone evaluation and management service (99443), the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), and the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359) rendered by the out-of-network (OON) provider on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the removal of residual tooth roots 
(cutting procedure)  (D7250), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated (D7210), crown - porcelain/ceramic (D2740), core 
buildup, including any pins when required (D2950), resin-based composite - one surface, posterior (D2391) 
resin-based composite - two surfaces, anterior (D2331), mandibular partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth (D5212), and maxillary partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) provided April 26, 2021, through May 17, 2021. 
 
You asked the Plan to provide additional payment for the tooth extractions, crowns, core buildup, fillings and 
upper and lower partial dentures. You say that you were told the services were covered. The Plan denied your 
request. The Plan says the record does not include evidence that you were told the services would be covered at 
100%.  The services have been covered according to your benefits. 
 
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. The Plan covers the tooth 
extractions, crowns, core buildup, fillings and upper and lower partial dentures when the services are medically 
necessary and reasonable.  
 
We looked at the file and Medicare rules. The documentation in the case file shows that you were charged 20% 
coinsurance for the fillings and extractions and 50% coinsurance for the remaining major restorative dental 
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 provide additional payment for the removal of residual tooth roots 
(cutting procedure)  (D7250), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated (D7210), crown - porcelain/ceramic (D2740), core 
buildup, including any pins when required (D2950), resin-based composite - one surface, posterior (D2391) 
resin-based composite - two surfaces, anterior (D2331), mandibular partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth (D5212), and maxillary partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) provided April 26, 2021, through May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation of muscle and does not 
have to waive the coinsurance for a Medicare Part B drug provided on September 4, 2020. 
 
You asked the Plan to waive the copayment for chemodenervation of muscle and to waive the coinsurance for a 
Medicare Part B drug. You say that you expected to owe a $35 copayment and disagree with the additional 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $220 
copayment for surgery services and 20% coinsurance for all other outpatient hospital services. You received chemodenervation of muscle at an outpatient hospital facility on September 4, 2020.  
Chemodenervation of muscle is considered an outpatient surgical procedure. Therefore, you are responsible to 
pay the $220 copayment.  
 
You received a Medicare Part B drug on September 4, 2020. The total allowed amount is $1,091.88 and 20% of 
that is $218.38.  
 
The total amount you owe is: $438.38.  
 
You have been asked to pay the total amount of $438.38 for chemodenervation of muscle and a Medicare Part 
B drug. Chemodenervation of muscle and a Medicare Part B drug fall within the outpatient hospital services 
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 chemodenervation of muscle and 
does not have to waive the coinsurance for a Medicare Part B drug provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiology visit you had on March 16, 2021.

You asked the Plan to waive the copayment for the cardiology visit. You say that because this was a follow-up visit from your surgery on March 2, 2021, there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 a $35 copayment for specialist visits.

You have been asked to pay a $35 copayment for the cardiology visit. According to Medicare rules, follow-up visits are only considered part of the surgery (and therefore not separately payable) if the follow-up visit occurs during the Medicare-approved postoperative period for the surgery. Each surgery service is given a postoperative period. For the surgery you had (cardiac catheterization), the postoperative period is only considered to be the day of surgery itself because this is a minor surgical procedure. That means that any follow-up visits after the date of surgery can be billed separately and a copayment can apply. 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 cardiology visit you had on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary, and considered safe and effective The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a 
therapeutic continuous glucose monitor. The Plan denied your request. The Plan says medical necessity cannot 
be established. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. There are no medical records in the case file to support criteria for a 
CGM. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic 
continuous glucose monitor.