Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health services beyond September 16, 2021.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you still meet the criteria for inpatient mental health care. You are not stable for discharge and still require acute inpatient mental health services. The Plan denied your request. The Plan says continued inpatient mental health services are not necessary beyond September 16, 2021.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that it is not medically necessary for mental health care to continue to be provided in an inpatient setting. Our physician reviewer found that you were involuntarily admitted to the acute inpatient psychiatric hospitalization on September 13, 2021. Based upon a review of the provided records, it is not expected that you will improve in a reasonable period of time beyond the dates in question as you are not showing any dangerousness to self or others, have no auditory or visual hallucinations and no aggressive behaviors. You are compliant with treatment and are not having side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health services beyond September 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for monovisc (J7327).

You asked the Plan to waive the coinsurance for monovisc. You say that the wrong cost share was applied. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for monovisc. monovisc falls 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 monovisc (J7327).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 12, 2021 to February 17, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not given an inpatient room due to a weather emergency. You say you should not have to pay for services you did not receive. The Plan denied your request. The Plan says the claim was reprocessed, and you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $335 copayment for per day, days 1-6 for in-network inpatient hospital care.
You have been asked to pay a $670 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows you were considered an inpatient for two days. ($335 x 2 = $670). 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 inpatient hospital stay provided from February 12, 2021 to February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for transfer to an LTACH. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. The enrollee was admitted to an outside hospital with a malrotation of the stomach and developed a perforation requiring partial gastrectomy. Subsequently he was transferred to the current facility for higher level care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH
services. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health services (90834)
provided from May 10, 2021, to May 24, 2021.
You asked the Plan to waive the copayments for the outpatient mental health visits. You say that the
copayments should be waived. The Plan denied your request. The Plan says the plan's COVID-19 waiver for
copayments ended December 31, 2020. The correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for outpatient mental health visits.
You have been asked to pay $70 (two $35 copayments) for two outpatient mental health visits. 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 outpatient mental health services (90834) provided from May 10,
2021, to May 24, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Gel-One. Our reviewer says that Gel-One (J7326) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs likely would be less effective and/or likely 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided to the enrollee on March 15, 2021.
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your request. The Plan says an approved referral from the primary care physician is needed.
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 telehealth services provided to the enrollee on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the pain is affecting the enrollee's every-day living. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental in spinal surgery. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office services provided on January 19, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the specialist office services. You say that you paid the $10 copayment and were billed for two (2) office visits on the same day. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you received specialist office services on January 19, 2021, by an in-network provider. According to your Explanation of Benefits (EOB), you were asked to pay a $35 copayment for the specialist office services on January 19, 2021. The clinic is a multiservice specialty practice.

You should only have the $35 copayment. Your 2021 EOC states that enrollees must pay a $35 copayment for each in-network Medicare-covered visit with a specialist. 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 specialist office services provided on January 19, 2021, by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 23, 2020.

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.

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 70450 is computed tomography, head or brain; without contrast material. We find that CPT code 70450 is payable when billed alongside code 70496, with an appropriate modifier. In this case, the records do not indicate an applicable modifier was billed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on April 26, 2021.

You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on March 12, 2021.
You asked the Plan to pay for the services provided. You say that the previous implants contained a steroid that could cause injury. The Plan denied your request. The Plan says the removal and replacement of implants were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician reviewer found that in this case, the record indicates you had subcutaneous saline implants. The record does not indicate the presence of a condition enumerated in the coverage criteria as an indication for implant removal. The elements of the coverage criteria are not satisfied. Therefore, the provided services were not considered 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound repair provided on January 22, 2021, by an OON
provider.

You asked the Plan to pay for the wound repair. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the wound repair provided on January 22, 2021, by an OON
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code 81545) provided to the enrollee on October 31, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that an in-network provider was the ordering physician. The Plan denied your request. The Plan says the ordering physician is not in-network with the enrollee's Plan.
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 (CPT code 81545) provided to the enrollee on October 31, 2020, by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). Medicare recognizes these Clinical Psychologists (CP) providers as eligible to provide diagnostic and Behavioral Health Integration (BHI) or Screening, Brief Intervention, and Referral to Treatment (SBIRT) services as permitted under state law. Required Qualifications: a. Psychology Doctoral degree b. Licensed or certified in the state where you practice at the independent level and directly provide diagnostic, assessment, preventive, and therapeutic patient services 1. Legally authorized to practice medicine in the state where you provide services 2. Medicare doesn't statutorily preclude the services, and they're reasonable and necessary 3. If the patient consents, you must attempt to consult their attending or primary care physician about provided services and either: a. Document consent or declination date to consultations and date of consultations in patient's medical record b. If consultations are unsuccessful, document the patient's medical chart with the date and physician notification method (doesn't apply if physician referred patient to CP) 4. You may generally supervise diagnostic psychological and neuropsychological tests
5. You may provide services and supplies incident to your professional services, except for hospital patient services You can find this information in Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network (MLN), Medicare Mental Health, MLN1986542.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on March 16, 2021.
You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on March 16, 2021.