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

We decided that the Plan does not have to pay for fluid flow treatment (Q4206) provided on December 16, 2020.
You asked the Plan to pay for fluid flow. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested service is an experimental/investigational procedure.
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 fluid flow. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested treatment is an experimental/investigational treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fluid flow have not been met. Therefore, we decided that the Plan does not have to pay for fluid flow treatment (Q4206) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of compliance with the device.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not using the device enough for it to be effective. The compliance report of 3/29 to 4/27 indicates 20% of days with at least four hours of usage, which does not meet the criteria. There are no clinical notes addressing the compliance issue or efforts to address it. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a general surgeon to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit with a general surgeon. You say that you are in severe pain and needs hernia surgery. You say you keep being referred to specialists that are unable to provide the service you need. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with a general surgeon 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 waive the copayment for the myelography via lumbar injection provided on October 22, 2020.
You asked the Plan to waive the copayment for the myelography via lumbar injection. You say that you were told by a representative that there would not be a copayment due to coronavirus relief. You say you want to be reimbursed. 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). Your contract with the Plan clearly says that you must pay a $350 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $350 copayment for the myelography via lumbar injection. The myelography via lumbar injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Please note, there is no provision in the contract which states an outpatient service will be waived due to coronavirus pandemic. 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 myelography via lumbar injection provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Barostim Neo system (0266T, C1825).
You asked the Plan to pre-approve a Barostim Neo system. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment 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 a Barostim Neo system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Barostim Neo carotid stimulation device implantation is a newer therapy which has very limited short term randomized data to support its use in improving quality of life and 6-minute walk capacity in patients who have persistent and significant symptoms of congestive heart failure (CHF) despite full guideline-directed medical therapy and are not candidates for resynchronization therapy. You are on only low doses of guideline-directed CHF medications and are not on any diuretics. Based on the limited data provided in the medical records, you do not currently meet the Food and Drug Administration (FDA) or published trial data criteria for Barostim Neo and therefore do not meet the medical necessity and reasonableness criteria of
the Medicare 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 a Barostim Neo system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Barostim Neo system (0266T, C1825).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal to be performed by an endodontist.
You asked the Plan to pre-approve root canal. You say that you need this redone or you will need more work.
The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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.
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 a
root canal to be performed by an endodontist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not
been met because the requested services are 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 that there is no documentation provided indicating medical necessity for the
requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where the
enrollee is 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 Plan.
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged telephone evaluation and management services provided on March 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the prolonged management and evaluation services. You say that the services were medically necessary and billed in error. The Plan denied your request. The Plan says the claim originally denied for not meet coding standards, but the services were not authorized.
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 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 prolonged telephone evaluation and management services provided on March 28, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab injection 100mg for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary for antibody-mediated rejection. The Plan denied your request. The Plan says that this is 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 the injection. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found antibody-mediated rejection is the B-cell-mediated production of immunoglobulin G antibody against the transplanted heart. The currently available therapies for antibody-mediated rejection have had marginal success, and chronic manifestations of rejection can result in an increased risk of graft vasculopathy and perhaps require repeat transplantation. Rituximab, a monoclonal antibody directed against the CD20 receptor of B-lymphocytes and approved as therapy for lymphoma, can be used in heart-transplant patients for the management of antibody-mediated rejection. The review has determined that the requested drug is safe and effective, and medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve Rituximab injection 100mg for the enrollee.
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 a referral for a consult with a plastic surgery specialist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care for abdominal pain related to a previous surgery is within the scope of a general surgery specialist.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have had several abdominal surgeries. You were seen in the emergency room and found to have hydronephrosis and significant constipation. There is a concern for adhesions. The records indicate that your condition is due intraabdominal pathology. A general surgeon is the appropriate specialist for evaluation. The record indicates that the request for a plastic surgeon consult is your preference. The condition being treated is not within the scope of practice of a plastic surgeon. The request for a plastic surgeon office visit is not medically necessary or reasonable, as defined by Medicare 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for a consult with a plastic surgery specialist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76536) provided March 29, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound is a screening service and should be covered in full. The Plan denied your request. The Plan says the correct copayment was applied.
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 $100 copayment for diagnostic radiology. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the diagnostic radiology 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 an ultrasound (76536) provided March 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97164) provided to the enrollee on
February 16, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 97164 GP KX (1 units) remains 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 97164 is "re-evaluation of physical therapy established
plan of care, requiring these components: An examination including a review of history and use of standardized
tests and measures is required; and revised plan of care using a standardized patient assessment instrument
and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the
patient and/or family."
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the
documentation includes a physical therapy re-evaluation for the date of service February 16, 2021. There is a more appropriate code to use in this case.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97164) provided to the enrollee on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on March 16, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that you do not know why the Plan isn't pay for anything. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $60 copayment for outpatient diagnostic tests/x-rays.
You have been asked to pay less than a $60 copayment for each x-ray. The total amount you are being asked to pay is $83.20 ($40.41 (foot) + $42.79 (ankle) = $83.20). An x-ray falls within the outpatient diagnostic tests/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 an x-ray provided by a participating provider on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged telephone evaluation and management services provided on February 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the prolonged management and evaluation services. You say that the services were medically necessary and billed in error. The Plan denied your request. The Plan says the claim originally denied for not meet coding standards, but the services were not authorized.

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 prolonged telephone evaluation and management services provided on February 27, 2021 by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says experimental and investigational services are not covered.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a blood specimen collection from an implanted device (36591) provided May 1, 2020.
You asked the Plan to waive the copayment for the blood collection. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $250 copayment for outpatient hospital services. You have been asked to pay the allowable amount of $110.73 for a copayment for the blood collection. The blood collection falls within the outpatient hospital services benefit category. The allowable amount is less than the $250 listed in the Evidence of Coverage. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a blood specimen collection from an implanted device (36591) provided May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 14, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on October 14, 2020.