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

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (CPT code 64636) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 physician reviewer found there is only one set of diagnostic MBBs documented. The LCD requires two (2) sets of diagnostic MBBs with 80% pain relief be documented. Therefore, at this point, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (CPT code 64636) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on March 12, 2021.

You asked the Plan to waive the copayment for specialist services. You say that you canceled this appointment and were not seen by anyone. 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 $35 copayment for specialist services. 

The medical records show that you received specialist services on March 12, 2021. Therefore, you are responsible to pay the $35 copayment. 

You have been asked to pay a $35 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on March 12, 2021.
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 you would benefit from prolonged respiratory treatments and therapies provided in the LTACH setting. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be more stable and only require short-term additional acute care services which can safely be administered at the current acute care facility for the time being. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as there is no advantage to transfer. Transfer to a lower level of care may be considered at a later date when treatment has completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) (K0554, K0553).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee's previous device is no longer covered. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. 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, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) (K0554, K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a follow-up office visit provided by a participating provider on March 24, 2021.
You asked the Plan to waive the copayment for a follow-up office visit. You say that you were told that the follow-up visit would be covered. The Plan denied your request. The Plan says the correct copayment has 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 $30 copayment for physician/practitioner services/specialty physician. You have been asked to pay a $30 copayment for a follow-up office visit. Follow-up appointments are subject to additional copayments; therefore, the correct copayment has been applied. A follow-up office visit falls within the physician/practitioner services/specialty physician 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 follow-up office visit provided by a participating provider on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on March 8, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that the tooth was too deteriorated and was not able to be saved. You say that the insurance would have covered the cost of the crown therefore, you are appealing this decision. The Plan denied your request. The Plan says the services are not covered 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 pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on March 8, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Myocardial perfusion imaging (78452).
You asked the Plan to pre-approve this service. You say that Myocardial perfusion imaging is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this service.
The Plan follows Medicare rules. Medicare rules say that noninvasive testing in the outpatient setting to assess for coronary artery disease (CAD) and left ventricular (LV) dysfunction may be accomplished by utilizing conventional exercise stress testing without imaging or by utilizing exercise or pharmacologic stress testing with imaging. Additionally, cardiovascular stress testing, also referred to as exercise stress test (EST), exercise electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information about how the heart responds to exertion. 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 this service. Our reviewer says that Myocardial perfusion imaging is medically necessary. Our physician reviewer found that although the Local Coverage Determination (LCD) guidelines for stress imaging recommends perfusion stress testing on a minimum two year repeat basis post coronary artery bypass graft surgery (CABG), this patient is a special situation given his high risk occupation (school bus driver). Given his clinical situation of post coronary bypass, the US Dept of Transportation (USDOT) published guidelines determined by an expert cardiology panel recommend yearly stress perfusion imaging testing for commercial bus drivers with this specific type of medical history. This specific clinical situation of high risk occupation post coronary revascularization is not addressed in the Centers for Medicare and Medicaid Services LCD for stress cardiac imaging. The listed LCD criteria are not applicable to this specific situation and therefore cannot be reasonably applied clinically to this situation. Based on the published criteria of the expert panel and the USDOT, a nuclear perfusion scan done post CABG > five years is medically reasonable and necessary at yearly intervals thereafter for working commercials bus drivers such as this patient. This is based on the published panel criteria, the specifics of this clinical situation and the enrollee's medical history and condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-approve Myocardial perfusion imaging (78452).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that if you do not get consistent 24-7 care from this facility, any other facility would stop your medical treatment, heart monitoring and endanger your health. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting and aortic valve replacement. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of the chest without contrast (71250).
You asked the Plan to waive the coinsurance for the CT scan of the chest. You say that you would like this copayment waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient diagnostic and therapeutic services and supplies. You have been asked to pay a total cost share of $98.40 for the CT scan of the chest which is less than the required $150 copayment. This service falls within the outpatient diagnostic 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 coinsurance for the computed tomography (CT) scan of the chest without contrast (71250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has primary osteoarthritis of the left knee. She has not tried and failed the Plan's required drugs, Orthovisc and Synvisc. The records do not show that the required drugs are contraindicated or less effective; therefore, Euflexxa is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on October 29, 2020, to November 11, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has 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 $295 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-
network. You have been asked to pay a $295 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. Your copayment total amount is $1,475. You are being asked to pay $1,295.50 due to reaching your out-of-pocket maximum. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider on October 29, 2020, to November 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a femur fracture after a fall. Medical conditions 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.
The patient 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. 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on April 1, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 physician services provided to the enrollee out of network on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic parenteral drug, single administration (D9610), the bone replacement graft for ridge preservation - per site (D7953) and the alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311).
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 the therapeutic parenteral drug, single administration (D9610), the bone replacement graft for ridge preservation - per site (D7953) and the alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311).