Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the computed tomography (CT) thorax (71250).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that medical necessity has not been established
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 CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the denial referenced in the leading paragraph of this case implies the request is for Low dose lung CT. This is not the case. The request is for CT of the chest without contrast, CPT 71250. This enrollee is described as having non quantified nicotine dependence and COPD, shortness of breath and wheezes. These symptoms qualify for establishing medical necessity for the requested CT of the chest. A recent chest x-ray would add little additional information and even if negative would not obviate the indication for chest CT. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve the computed tomography (CT) thorax (71250).
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: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a SNF stay. We decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for a SNF stay. You say that you have money taken out of your social security and feel that hospital charges should be included in that. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $920 to $736.
The Plan says that you must pay a $920 copayment for a SNF stay. However, you cannot be asked to pay a copayment for the day you are discharged. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $920 to $736.
We also decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.
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 $0 copayment for days 1-20, and a $184 copayment for days 21-57 for a SNF stay. You had a SNF stay from January 7, 2021, to January 31, 2021. You are not being asked to pay a copayment for days 1-20 (January 7, 2021, to January 26, 2021). You are responsible to pay a $184 copayment for days 21-24 (January 27, 2021, to January 30, 2021). The total amount you owe is: $184 (copayment) x 4 (SNF days) = $736. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.
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 out of network physician services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says you have seen this provider in the past without prior authorization and you have been made aware that you can be treated 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 provider 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 out of network physician services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable neurostimulator, pulse generator (CPT code L8679), for the enrollee
You asked the Plan to pre-approve the DME. You say that based on the enrollee's history and diagnoses, you are recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says the enrollee used injections and electrical stimulation for the foot pain without adequate relief. The Plan states the device requested, an Auricular Stimulator, stimulates cranial nerves to try to diminish pain. The Plan states the procedure includes placement of a device behind the ear for electro-acupuncture stimulation of the auricular nerve and it is a form of acupuncture.
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 DME. Our physician reviewer found the Medicare guidelines say that electroacupuncture is not a covered service, as it is new agent of unknown use and efficacy in the United States. The review has determined that the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantable neurostimulator, pulse generator (CPT code L8679), for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
You asked the Plan to pre-approve additional home health skilled nursing visits. You say that home health skilled nursing services are medically necessary. The Plan denied your request. The Plan says the criteria for additional home health skilled nursing services have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Records indicate her pressure ulcer is healed. In addition, a home health nursing note of August 19, 2021, reports the enrollee requested discharge from home health services and she waived the five day discharge notice due to improvement in her conditions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee.
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 are no records that support the need for these visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 medically reasonable or necessary. Our physician reviewer found there are no documented skilled therapy needs. The enrollee is functioning at a level commensurate with a lower level of care. As such, the requested ongoing home health services are not shown to be medically necessary or reasonable. 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 home health physical therapy services for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs provided from January 12, 2021, to February 4, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree with the charges because you thought that the infusions would be a continuation from a previous swing bed stay. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from January 12, 2021, to February 4, 2021, for a total of 22 services. The
total allowed amount per each date of service is: $114.79 and 20% of that is $22.96. $22.96 (coinsurance) x 22 (dates of service) = $505.12. You received a Medicare Part B drug on January 14, 2021. The total allowed amount is $106.40 and 20% of that is $21.28. The total amount you owe is: $505.12 + $21.28 = $526.40. You have been asked to pay the total coinsurance amount of $526.40 for Medicare Part B prescription drugs. Medicare Part B prescription drugs fall 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 Medicare Part B prescription drugs provided from January 12, 2021, to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from January 3, 2021, to January 29, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. You say that you have been on dialysis for 7 years and you feel as though your coverage changed after you purchased it. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that your benefits did change between 2020 and 2021, but you were sent an Annual Notice of Change that advised of the cost sharing change for dialysis services.
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 dialysis services.
You have been asked to pay 20% coinsurance for the dialysis 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 waive the coinsurance for dialysis services you received from January 3, 2021, to January 29, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on April 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for diagnostic imaging. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring 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 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 diagnostic imaging provided on April 26, 2021 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 two (2) office visits with a specialist (99204, 99213) provided on October 30, 2020, and November 20, 2020.
You asked the Plan to waive the copayment for office visits. You say that you were told the waiver for a
specialist copayment had been waived through December 31, 2020. You also say that your friends and family
that have the same plan were also told specialist copays were waived until December 31, 2020. The Plan
denied your request. The Plan says the copayment you are being charged is correct.
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 per visit for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $35 copayment per visit, for office visits with a specialist. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Please note, the Plan waived costshares
for specialist services between May 11, 2020, and September 30, 2020. The dates of service for the
claims at issue do not fall within this timeframe. The EOC confirms $35 is the required copayment for each
visit. 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 two (2) office visits with a specialist (99204, 99213)
provided on October 30, 2020, and November 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 22, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you do not think you should have to pay this copayment because you only went to the ER to get your blood pressure checked. You said that you did not receive any other services. 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 $120 copayment for visits to the emergency room. You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of the extent of services you receive during your ER visit. 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 emergency room (ER) visit you had on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the facet joints.

You asked the Plan to pre-approve the RFA procedure. You say that the enrollee has had the required pain relief from two facet joint injections and had sustained pain relief from the prior RFA procedure for nearly ten months. As this pain is now beginning to return, a repeat RFA procedure is necessary. The Plan denied your request. The Plan says the criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that RFA of the facet joints is covered after two injections provide at least 80% pain relief. A repeat RFA requires 50% pain relief for at least 6 months.

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 RFA procedure. Our reviewer says that the requested RFA procedures are not considered medically reasonable and necessary. Our physician reviewer found the enrollee is an 82 year old male with chronic back pain due to lumbar scoliosis, lumbar degenerative disc disease, and lumbar spondylosis without myelopathy. The medical records from office visit 08/09/2021 state the member has not had any previous treatments; no physical therapy, manipulation, or acupuncture. It does note the member takes an 800mg Ibuprofen as needed but does not say if it relieves the pain or how often he takes it. The member had previous right-sided lumbar facet joint medial branch nerve radiofrequency neurotomy on 10/13/2020. There is no mention of baseline pain or pain relief with any therapies or treatments from the past.

Based on the medical records, none of the criteria have been met in regards to documented pain and pain relief, a comprehensive treatment plan, non-invasive/conservative therapies tried, nor the use of any pain scale after previous procedures in the past. The enrollee does not meet criteria for the repeat RFA of the facet joint nerves. 

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 RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the facet joints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for radiology, laboratory services, radiation therapy and office visits provided on January 1, 2021, to April 26, 2021.

You asked the Plan to waive the cost-shares for radiology, laboratory services, radiation therapy and office visits. You say that if it was not for Covid-19, you would have completed your treatment in 2020, which would have reduced your expenses since you would have met your plan's 2020 maximum out-of-pocket. The Plan denied your request. The Plan says the cost-shares you are being charged are correct.

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 $40 copayment for physician/practitioner services, including doctor's office visits. Your contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay copayments and coinsurances for radiology, laboratory services, radiation therapy and office visits. The EOC confirms the cost-shares charged are correct. Additionally, the record indicates that as of April 30, 2021, your in-network, out-of-pocket costs have reached $2,971.36 that count toward your $3,400.00 out-of-pocket maximum for covered 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 waive the cost-shares for radiology, laboratory services, radiation therapy and office visits provided on January 1, 2021, to April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services.

You asked the Plan to pre-approve personal care services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that custodial care is excluded from coverage. 

We looked at the file and Medicare rules. The requested custodial care services are not covered by Medicare or the enrollee's plan. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services.