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

We decided that the Plan does not have to pay for ophthalmic imaging (92134), corneal topography (92025) and echography exam of the eye (76519) provided on October 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 ophthalmic imaging (92134), corneal topography (92025) and echography exam of the eye (76519) provided on October 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous blood glucose monitor (CGM).

You asked the Plan to preapprove the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria.

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.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous blood glucose monitor (CGM).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's current level of functions suggests that his needs can be provided in an alternate setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient is living at home and has weakness from post polio syndrome and decubitus ulcers. He is receiving home health services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that this was a medically necessary service provided to an enrollee in a skilled nursing facility. The Plan denied your request. The Plan says they do not cover out-of-network services, except in limited circumstances. The services provided were not urgent or pre-approved and could have been provided in-network. It is the responsibility of either the provider or the facility to verify the enrollee's eligibility and obtain prior authorization for care.
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 subsequent nursing facility care (99307) provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin.
You asked the Plan to pre-approve Oxycontin. You say that the enrollee requires additional pain relief to have a decent quality of life. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Oxycontin.
Benefits for Oxycontin 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 waive the coinsurance for the pacemaker surgery (33208) provided on August 17, 2020.
You asked the Plan to waive the coinsurance for the heart surgery. You say that this was medically necessary surgery, and you believe the Plan should cover your cost-sharing responsibility. The Plan denied your request. The Plan says cost-sharing is your responsibility according to the Plan's contract. The Plan also states that the amount requested from you is less than the full coinsurance because you met your out-of-pocket maximum with this claim.
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 outpatient surgery. You have been asked to pay $1,307.02 for heart surgery provided at an outpatient facility. The provider billed the Plan for $12,553, but the Plan's allowed amount for this service is only $9,935.16 ($9,935.16 x 20% = $1,987.03). The Plan provided documentation that you had already paid $192.98 for services which contributed to your out-of-pocket maximum of $1,500. Therefore, the Plan charged you $1,307.02 ($192.98 + $1,307.02 = $1,500) instead of the full 20% ($1,987.03). 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 pacemaker surgery (33208) provided on August 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a duplex scan and an ultrasound provided on September 10, 2020.
You asked the Plan to waive the copayments for a duplex scan and an ultrasound. You say that you should only owe a $160 copayment for ultrasounds. 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 $160 copayment for each radiological diagnostic service. You received a duplex scan on September 10, 2020. Therefore, you are responsible to pay the $160 copayment. You received an ultrasound on September 10, 2020. Therefore, you are responsible to pay the allowed amount of $101.95, which is less than the $160. The total amount you owe is: $261.95. You have been asked to pay the total copayment amount of $261.95 for a duplex scan and an ultrasound. A duplex scan and an ultrasound fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for a duplex scan and an ultrasound provided on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on November 10, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you thought that the test would be considered a breast cancer screening. 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 $300 copayment for advanced imaging. You received an MRI of the breast on November 10, 2020. An MRI is not included in a breast cancer screening. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on November 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the service is medically necessary. The Plan denied your request. The Plan says services can be obtained in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and the beneficiary does not require skilled nursing or therapy services on a daily 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 admission to a SNF have not been met. Specifically, the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. This means admission to a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a parotid excision (42420) provided on September 28, 2020.
You asked the Plan to pay for a parotid excision. You say that this code is supported. The Plan denied your request. The Plan says this is not documented.
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 42420 is excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve. 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 a parotid excision. Our reviewer says that code 42420 is not supported. Our physician reviewer found the operative report does not include enough documentation to confirm a total parotidectomy and facial nerve monitoring was performed. 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 parotid excision have not been met. Therefore, we decided that the Plan does not have to pay for a parotid excision (42420) provided on September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 26, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the requested ambulance services were not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on September 26, 2020. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 26, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve abdominal magnetic resonance imaging and pelvic magnetic resonance imaging (MRI).
You asked the Plan to pre-approve a Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (74183) and a Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (72197). You say that the enrollee needs the MRIs. The Plan denied your request. The Plan says that there is no evidence a cystoscopy was completed.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (74183) and a Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (72197). Our reviewer says that the MRIs are reasonable and medically necessary. Our physician reviewer found this patient is considered high risk for malignancy and clinicians should perform cystoscopy and axial upper tract imaging in patients with microhematuria. If there are contraindications to multiphasic Computed Tomography (CT) urography, clinicians may utilize Magnetic Resonance urography. This patient has chronic renal insufficiency, and this is a contraindication to CT urography with contrast. 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 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (74183) and a Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (72197) have been met. Therefore, we decided that the Plan has to pre-approve abdominal magnetic resonance imaging and pelvic magnetic resonance imaging (MRI).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a test to evaluate wheezing (94060)
provided on August 14, 2020, and laboratory services (84153, 36415) provided on August 24, 2020.
You asked the Plan to waive the copayment for a test to evaluate wheezing, and laboratory services. You say
that you would like the Plan to refund you because you believe you are paying for medical services that are not
warranted. The Plan denied your request. The Plan says the copayments were applied 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 $15
copayment for outpatient diagnostic tests, and a $15 copayment for laboratory services.
You have been asked to pay a $15 copayment for a test to evaluate wheezing, and a $15 copayment for
laboratory services. A test to evaluate wheezing falls within the outpatient diagnostic tests benefit category, and
laboratory services fall within the laboratory 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 a test to evaluate wheezing (94060) provided on August 14, 2020, and laboratory services
(84153, 36415) provided on August 24, 2020.
Your complaint about your belief that you are paying for medical services that are not warranted 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation services (R0070) provided on September 16, 2020.
You asked the Plan to pay for x-ray transportation services. You say that this should be covered. The Plan denied your request. The Plan says this must be billed by the SNF.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B. By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing. We looked at the file and Medicare rules. The x-ray transportation at issue was provided to a SNF resident and cannot be separately billed. Based on this information, we decided that Medicare rules for coverage of x-ray transportation services have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation services (R0070) provided on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc 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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason why they would be unsafe or ineffective for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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.