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

We decided that the Plan does not have to waive the copayments for the application of a multi-layer compression systems provided from July 9, 2021, to July 30, 2021.
You asked the Plan to waive the copayments for the application of a multi-layer compression systems. You say that you disagree with the surgery charges because the enrollee did not receive an operating room service and only received wound care. The Plan denied your request. The Plan says the claims were processed correctly and they 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The enrollee received the application of a multi-layer compression system from an outpatient hospital facility from July 9, 2021, to July 30, 2021, for a total of 4 visits. The application of a multi-layer compression system is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the total allowed amount of $776.49, which is less than the total copayment amount. The enrollee has been asked to pay the total amount of $776.49 for the application of a multi-layer compression systems. The application of a multi-layer compression systems falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the application of a multi-layer compression systems provided from July 9, 2021, to July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve insertion of a Vertiflex device. You say that the requested service is medically necessary for the enrollee as this treatment is considered safe and effective. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use.
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 a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a Vertiflex device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on May 26, 2021.
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 procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care time. 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 pay for the critical care services rendered on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due
to insufficient evidence of efficacy.
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 the procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the
device.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on June 2, 2021.
You asked the Plan to pay for the services provided. 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 code.
We looked at the file and the rules. We find that CPT code 11043 was billed with code 15275. The CPT code at
issue, 11043 may be eligible for payment when billed with a modifier. The medical records provided do not
show that the service billed with the -59 modifier is a distinct procedural service. 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 debridement services provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay $200 for the eyeglasses. We decided that the Plan does not have to fully pay for the eyeglasses.
You asked the Plan to pay for the eyeglasses. You say that you have submitted the receipt and claim for payment 4 times and still have not received payment. The Plan says that the claim denied correctly as an itemized bill was not received.
We decided that the Plan has to pay up to $200 toward the frames and lenses.
The Evidence of Coverage clearly says that you have $200 toward the purchase and fitting of eyeglasses and a pair of lenses. The receipt submitted shows you purchased frames and lenses. Therefore, we decided that the Plan has to pay $200 toward the eyeglasses. You are responsible for the amount over $200.
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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray you had on July 21, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that you were not aware there would be a copayment for this service. 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 $30 copayment for x-rays.   You have been asked to pay a $30 copayment for the x-ray. 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 x-ray you had on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on July 23, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that the laboratory services should be part of the physical. You say you do not feel you should have to pay for something that was done at the doctor's request. The Plan denied your request. The Plan says you have been charged 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 $5 copayment for laboratory tests that are not fecal immunochemical tests (FIT). You have been asked to pay a $5 copayment for the laboratory services. The laboratory services fall within the
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 while the enrollee may benefit from physical and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services (CPT code G0299 X 5).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your vital signs, taken by the home health nurse, are stable. The Plan states there have been no recent changes to your treatment plan or your medications. The Plan states your medical condition has not changed recently and you have not been taken to the emergency room or re-admitted to the hospital recently. The Plan states no pain was reported to the nurse and your records do not support the need for a skilled nurse to make more 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 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 your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Records from your most recent home health nursing evaluation on December 2, 2021, do not document any acute or unstable medical conditions which would necessitate any further skilled nursing visits beyond what have already been approved. You did have a fall on November 27, 2021, with 2/10 ankle pain reported with swelling but no skin changes and no open wounds. No other injuries or issues were reported. No new treatments with regard to your gait or Parkinson's disease were reported. Records indicate your spouse was instructed on safety and fall precautions at this visit. The health plan indicated further home health services would be considered if documentation from your physician indicated a need for such 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services (CPT code G0299 X 5).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration provided on June 22, 2021.

You asked the Plan to pay for the chemotherapy administration. You say that the chart notes are provided, and
the claim should be reprocessed for payment. The Plan denied your request. The Plan says code 96401 remains
denied as there is a more appropriate code for the services provided.

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 96401 is chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic.

We asked our coder 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 chemotherapy administration. Our reviewer says that this
does not meet the criteria for reimbursement consideration. Our reviewer found that the medical records
indicate the patient presented for a Prolia injection J0897. Our reviewer says that the appropriate administration
code to submit with J0897 is 96372 - (Therapeutic prophylactic, or diagnostic injection (specify substance or
drug); subcutaneous or intramuscular. Therefore, CPT code 96401 is not eligible for reimbursement.

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 chemotherapy administration have not been met. Therefore, we decided that
the Plan does not have to pay for the chemotherapy administration provided on June 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Palonosetron (J2469).
You asked the Plan to pre-approve Palonosetron. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment 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 Palonosetron. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that Palonosetron is approved by the Food and Drug Administration for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses in adults treated with moderately to highly emetogenic cancer chemotherapy. The combination of Gemcitabine and Docetaxel prescribed for the enrollee is only mildly emetogenic. In addition, there is no documentation that the enrollee had had a trial of drugs Dexamethasone, Metoclopramide, Prochlorperazine, Dolasetron, Granisetron, or Ondansetron. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Palonosetron (J2469).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635).

You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two medically reasonable and necessary diagnostic medial branch blocks, with each one providing a consistent minimum of 80% sustained relief of primary 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 radiofrequency ablation procedure. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the enrollee has not undergone a first or second confirmatory set of diagnostic medial branch blocks being performed to the left L5-S1 region. 

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 radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression bandages identified with codes A6449, A6441, A6450, and A6448.
You asked the Plan to pre-approve the compression bandages. You say that the bandaging is for your lymphedema to reduce swelling in the lower extremities. You say that the need is not related to wound care. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression bandages identified with codes A6449, A6441, A6450, and A6448.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) of the abdomen and/or pelvis (74174) rendered on June 29, 2021.
You asked the Plan to waive the copayment for computed tomography (CT) of the abdomen and/or pelvis. You say that had you known about the high cost of the copayment, you would have declined the procedure since the report of the vascular ultrasound showed no changed that would require further intervention. You also say that you do not feel you should be responsible for the copayment as you were never informed of the cost. The Plan denied your request. The Plan says you were charged 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 $150 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $150 copayment for a computed tomography (CT) scan of the abdomen and/or pelvis. Computed tomography (CT) scans of the abdomen fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) of the abdomen and/or pelvis (74174) rendered on June 29, 2021.
Your complaint about potentially not being to speak to the provider and the potential unnecessary testing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided to the enrollee on May 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that these codes do not require a primary care physician referral. The Plan denied your request. The Plan says that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient hospital services provided to the enrollee on May 26, 2021 by an out-of-network (OON) provider.