Persius/hicric huggingface dataset:
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 service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 medical record does not indicate that the enrollee requires services that they are
not already receiving at current 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 the LTACH services have not been met. Specifically, there are no services
offered at a LTACH that the enrollee is not already receiving at their current level of care. This means
admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to preapprove
LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 18, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics for Covid systems. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drugs, and the specialist visit
provided from January 13, 2021, to January 27, 2021.
You asked the Plan to waive the cost share for the Part B drugs and the specialist visit. You say that you feel
you should not be responsible for this cost share amount and you would like the Plan to reconsider your
request. The Plan denied your request. The Plan says you received Part B drugs and a specialist visit on the
dates of service at issue in this appeal. The Plan says the correct cost share has applied per your contract with
the Plan.
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 Medicare Part B prescription drugs and a $40 copayment for physician specialist services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B injections
on January 13, 2021 provided by a specialist. You have been asked to pay a 20% coinsurance for the Part B
injections at $28.06 per injection, totaling $56.12. The Part B drugs fall within the Medicare Part B prescription
drugs benefit category. You have been asked to pay a $40 copayment for the specialist services. The specialist
services fall within the Physician/Practitioner services benefit category.
The file also shows that you received Part B injections and specialist services on January 27, 2021. You have
been asked to pay a 20% coinsurance for the Part B injections at $27.03 per injection, totaling $54.06. You
have also been asked to pay a $40 copayment for the specialist services.
This means that you have been asked to pay the correct amounts 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 cost share for the Part B drugs, and the specialist visit provided from
January 13, 2021, to January 27, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a subacute left parietal stroke. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but 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: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the nuclear stress test provided on January 13, 2021.
You asked the Plan to waive the copayment for the nuclear stress test. You say that you did not have a nuclear stress test. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the medical records. We are unable to confirm if a nuclear stress test was performed which means we cannot verify if the copayment amount is correct. Therefore, we decided that the Plan has to waive the copayment for the nuclear stress test provided on January 13, 2021.
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 repeat radiofrequency ablation (RFA) of the nerves of
left facet joints.
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with
imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or
sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636). You say
that the enrollee suffers from persistent axial low back pain. The Plan denied your request. The Plan says the
records do not show the last procedure improved the enrollee's pain by at least 50% for 6 months or more.
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 neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet
joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for
primary procedure) (64636). Our reviewer says that the requested services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the pain relief lasted only 3 months at
50%. This does not meet the criteria for repeat RFA. The request is 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 neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional
facet joint (List separately in addition to code for primary procedure) (64636) have not been met. Therefore, we
decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) of the nerves of left
facet joints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326) injections.
You asked the Plan to pre-approve the Gel-One injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says a trial of Euflexxa is required before alternatives can be considered.
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 Gel-One injections. Our reviewer says that Gel-One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug, or any reason why the plan preferred drug would be unsafe or ineffective. 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 Gel-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326) injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the heart with calcium scoring.
You asked the Plan to pre-approve the scan. You say that this is medically necessary to understand if the arteries are blocked or narrowed. The Plan denied your request. The Plan says this is not a Medicare-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CT 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 imaging is not medically reasonable or necessary. Our physician reviewer found there are no history or symptoms of ischemic heart disease. There is no diagnosis of hypertension or diabetes. There is reported hyperlipidemia but no fasting lipid profile is provided. Coronary calcium CT scoring can sometimes be indicated in patients with borderline/intermediate ten year risk of cardiovascular disease based on CV risk factor calculation when statin therapy is being considered as part of a shared decision making model. There are no records provided regarding this consideration of lipid lowering therapy and in the absence of fasting lipids, a determination of CV risk cannot be made. Based on the medical records provided, CT calcium scanning would therefore not meet AHA/ACC published indications for use and would not be considered medically reasonable and necessary per the applicable CMS rules. 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-approve a CT scan of the heart with calcium scoring.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility admission provided from March 4, 2020, to March 10, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation facility admission. You say that you were informed that there would be no additional charge once the enrollee was transferred. You say the services were covered in the charges paid for the inpatient hospitalization. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that they must pay a $300 copayment for each day for days 1 to 6 for in-network Medicare-covered hospital care. The enrollee has been asked to pay a $300 copayment per day, for days 1 to 6, for the inpatient rehabilitation facility admission. ($300 x 6 days = $1,800). The inpatient rehabilitation facility admission falls within the "Inpatient Hospital Care" benefit category. The record shows the inpatient rehabilitation facility admission is separate from the inpatient hospital admission.
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 inpatient rehabilitation facility admission provided from March 4, 2020, to March 10, 2020.
Your complaint that the charges are unethical is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on December 17, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you were told that this visit would not cost anything. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $981.12. The total amount you are being asked to pay is $196.22 ($981.12 x 20% = $196.22). An injection falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided by an out-of-network provider on February 17, 2021.

You asked the Plan to pay for the annual wellness visit. You say that you were looking for a physician that would give you better care and this provider was referred to you. You say that the provider's office told you they accept your healthcare, and the service should be covered. The Plan denied your request. The Plan says in-network providers were available.

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. 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 annual wellness visit provided by an out-of-network provider on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the office visit provided on January 6, 2021.

You asked the Plan to waive the co-payment for the office visit. You say that nobody should be getting paid for something they didn't do. You say that they said you did not owe anything, and you shouldn't have to pay $45.20. The Plan denied your request. The Plan says the claim reprocessed to remove the deductible and the $35 co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for each in-person specialist visit.

You have been asked to pay a $35 co-payment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was with a specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the office visit provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99232) provided January 26, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed are not separately payable.
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 99232 is not supported in the medical record. Specifically, post-operative visits performed during the post-operative period of a global surgery that are related to the recovery from that surgery are included in the global surgical package and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99232) provided January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up vaccination received on April 6, 2021.

You asked the Plan to pay for the services. You say that you are careful about appropriate checkups and medications. The Plan denied your request. The Plan says this only covered under the Part D benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for a follow-up vaccination received on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on November 26, 2020.
You asked the Plan to pay for the services provided. You say that the testing was ordered as part of the enrollee's treatment plan. The Plan denied your request. The Plan says the testing was not approved by the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic test must be ordered by the physician who is treating the enrollee for a specific medical problem.
We looked at the file and the rules. The documentation in the case file shows that the testing was not ordered or authorized by the enrollee's treating physician. The medical records provided do not clearly document the intent for the testing to be performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided on November 26, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device provided on June 4, 2020 and billed with CPT codes 97112, 97016, 96372, 97032, J3490, J3415 and J3411.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that you would like reconsideration because the billed services are medically necessary and not experimental. The Plan denied your request. The Plan says 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 pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient clinical evidence to support that Sanexas neoGen-Series Therapy (electrical cell stimulation and neuromuscular re-education) and vasopneumatic devices modality positively impact outcomes in patients with chronic pain syndrome, and bilateral foot pain. 

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 nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device provided on June 4, 2020 and billed with CPT codes 97112, 97016, 96372, 97032, J3490, J3415 and J3411.