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

We decided that the Plan does not have to pre-approve right-sided facet joint injections for levels C3-C5.

You asked the Plan to pre-approve the cervical facet joint injections. You say that it is felt that this should be tried to alleviate his pain. The Plan denied your request. The Plan says facet joint interventions are not supported as the enrollee has signs of radiculopathy including cervical stenosis.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered reasonable and necessary when there is a failure of conservative treatments and no other potential sources of pain. 

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 cervical facet joint injections. Our reviewer says that the requested services are not shown to be medically reasonable and necessary at this time. Our physician reviewer found the enrollee has chronic neck pain with radiation to his should. There is no documentation regarding response to physical therapy or medications. Imaging shows C3-C4 spinal stenosis. 

The criteria are not met as the enrollee has not had an adequate trial of conservative therapy and also has another clear source of pain. Therefore, the request is deemed 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 cervical facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve right-sided facet joint injections for levels C3-C5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services you received from May 18, 2021, to May 20, 2021.

You asked the Plan to waive the copayment for the outpatient hospital observation services. You say that if you are in the hospital for several days, you don't think that should be considered outpatient. 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 $275 copayment for outpatient hospital observation services.

You have been asked to pay a $275 copayment for the outpatient hospital observation services. The medical records confirm that you were in outpatient hospital observation and were not admitted as an inpatient. Your Evidence of Coverage states that you can be considered an outpatient even if you stay in the hospital overnight. 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 outpatient hospital observation services you received from May 18, 2021, to May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce your cost sharing for the computed tomography (CT) scan of the abdomen and pelvis, the magnetic resonance imaging (MRI) of the middle spinal canal, and MRI of the lower spinal canal you had on July 1, 2021.
You asked the Plan to reduce your cost sharing for the CT scan and two MRIs. You say that you have always been responsible for one copayment per date of service. You feel as though being charged a separate copayment for each service is excessive. The Plan denied your request. The Plan says you were charged these copayments 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 $250 copayment for diagnostic radiology services.
You have been asked to pay a $250 copayment for each service (the CT scan and two MRIs.) Copayments are charged on a per-service basis, not per-day, unless your contract explicitly states otherwise. 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 reduce your cost sharing for the computed tomography (CT) scan of the abdomen and pelvis, the magnetic resonance imaging (MRI) of the middle spinal canal, and MRI of the lower spinal canal you had on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation service (99153) provided on December 7, 2020.

You asked the Plan to pay for sedation. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code may not be paid if furnished to a hospital inpatient or outpatient

The Plan must follow Medicare rules. Medicare rules say that code 99153 is a technical component only code for selected diagnostic tests for which there may or may not be an associated code that describes the professional component. Medicare rules also say that the technical component of a diagnostic service furnished to a hospital outpatient is paid under the Outpatient Prospective Payment System to the hospital. 

We looked at the file and Medicare rules. This code is a technical component only code; therefore, this service is paid under the Outpatient Prospective Payment System to the hospital and is not separately payable. Based on this information, we decided that Medicare rules for coverage of sedation have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation service (99153) provided on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 laboratory services provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for pain management. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available who can provide this requested service. 
 
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 
a referral out-of-network for pain management.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been 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 Euflexxa. Our reviewer says that the requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation indicating that the Plan's required drugs would likely be less effective or have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 7 home health physical therapy (PT) visits.

You asked the Plan to pre-approve the additional home health visits. You say that the enrollee continues to be a fall risk and would benefit from ongoing therapy in the home. The Plan denied your request. The Plan says with the two additional PT visits, the enrollee should be able to be established in a home exercise program to allow for her condition to be maintained.

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 additional home health visits. Our reviewer says that the requested additional home health therapy services are not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a female who has been receiving home physical therapy for dizziness with falls. The most recent therapy documentation indicates the member is able to ambulate up to 200 feet with a rollator. She requires minimal to no assistance for transfers and bed mobility. There has not been a recent decline in function and the member has been medically stable. The health plan has authorized 2 of the 9 originally requested home health visits.

In this case, the documentation does not support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The health plan has authorized an additional 2 visits which should be enough to establish a home exercise program.

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 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 7 home health physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (15733) provided on June 22, 2020.
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that the records do not support the code billed. Our coding reviewer found the operative note states that the flap was based on the labial artery. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
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 muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (15733) provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam and related services you had on October 21, 2020.

You asked the Plan to waive the copayment for the medical eye exam. You say that you feel as though you shouldn't pay this copayment because the office didn't dilate your eyes or diagnose your cataracts. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it has not received a bill yet for the eyeglasses or dilation, so this appeal is limited to the medical eye exam.

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 medical eye exams.

You have been asked to pay a $40 copayment for the medical eye exam. This copayment applies regardless of your satisfaction with the 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 copayment for the medical eye exam and related services you had on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit (99213) provided on March 1, 2021.
You asked the Plan to reimburse you for the office visit. You say that you would like reconsideration because you received a full reimbursement for the same service previously. The Plan denied your request. The Plan says you are responsible for the cost share applied to this service.
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 $10 copayment for Physician Services. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician 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 reimburse you for the office visit (99213) provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim has not been processed by the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that they have not received an Explanation of Benefits (EOB) from the primary insurer for the claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided from January 4, 2021, to March 10, 2021.
You asked the Plan to pay for these services. You say that you were under the impression out of network services are covered. The Plan denied your request. The Plan says out of network services are covered, however services from providers who do not participate in the Medicare program are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. These services were provided by a physician who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided from January 4, 2021, to March 10, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (upper
GI endoscopy) you had at an outpatient hospital facility on March 18, 2021.

You asked the Plan to waive the copayment for the upper GI endoscopy. You say that this procedure was
ordered by your primary care doctor, so it should be covered. 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 $350
copayment for surgery or other services provided at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the upper GI endoscopy. The upper GI endoscopy falls
within the surgery or other services provided at an outpatient hospital facility 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 the esophagogastroduodenoscopy (upper GI endoscopy) you had at an outpatient hospital facility on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an over-bed table and a back-and-neck pillow provided on 
April 14, 2021, by an online retailer that is not enrolled in the Medicare program. 
 
You asked the Plan to pay for an over-bed table and a back-and-neck pillow. You say that the requested items 
were a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been 
met because the supplier at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an over-bed table and a back-and-neck 
pillow provided on April 14, 2021, by an online retailer that is not enrolled in the Medicare program.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the pelvis (72170) rendered by the out-of-network (OON) provider on May 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the pelvis (72170) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) 
provided from April 20, 2021, through April 27, 2021. 
 
You asked the Plan to pay for non-emergency transportation, wheelchair van. You say that you need this 
transportation to get to your physical therapy visits. You say the only way to get out of the house is through the 
back door and you require a wheelchair to go through the hilly backyard and to the driveway. The Plan denied 
your request. The Plan says the member has exhausted the transportation benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) provided from 
April 20, 2021, through April 27, 2021.