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

We decided that the Plan does not have to pre-approve Ilumya (J3245).

You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Ilumya.

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 Ilumya. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives. Our reviewer also found that the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternatives. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 31,
2021, by an out-of-network provider.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not
been met.

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 psychotherapy services (90837) provided on
August 31, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of a surgical assistant at a surgical endoscopy of the wrist (29848) and a tendon sheath incision (26055) provided on June 9, 2021.

You asked the Plan to pay for the services of a surgical assistant. You say that the services of a surgical assistant were a medical necessity for the enrollee's care. The Plan denied your request. The Plan says the services of a surgical assistant for the procedures at issue are not a covered benefit.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 29848 and 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services of a surgical assistant have not been met. Therefore, we decided that the Plan does not have to pay for the services of a surgical assistant at a surgical endoscopy of the wrist (29848) and a tendon sheath incision (26055) provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on September 21, 2021.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by your Plan if performed by a participating provider and performed as a routine screening.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on September 21, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that by not providing
coverage, the Plan is out of compliance with Medicare guidelines. You say that the patient has failed more than
12 years of conservative treatment and the necessary coverage should be provided. The Plan denied your
request. The Plan says neither Medicare nor the Plan cover this service.
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 insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that interlaminar spacer devices remain experimental. Our
reviewer says that 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 the insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral brachioplasty services.
You asked the Plan to pre-approve the requested services. You say that you get yeast infections. The Plan denied your request. The Plan says the procedure is considered cosmetic.
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 requested services. Our physician reviewer found that in this case, the record indicates that you have batwing deformities bilaterally. The record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral brachioplasty services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99348, 99349) rendered by the out-of-network (OON) provider on May 25, 2021 and
May 27, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99348, 99349) rendered by the out-of-network (OON) provider on May 25, 2021 and May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for ophthalmological services, medical examination provided on February 16, 2021.
You asked the Plan to pay an additional amount for the ophthalmological services, medical examination. The Plan denied your request. The Plan says the claim was paid with the correct Medicare allowable rate.
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 the full amount for care from out-of-network providers only in cases
involving emergencies, out of area urgent care and pre-approved care. The contract with the Plan also says
when you receive care from an out-of-network provider in the US or its territories, you may be asked to pay
more than if you got the care from a network provider.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay an additional amount for these
services. Therefore, we decided that the Plan does not have to pay an additional amount for ophthalmological
services, medical examination provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation -
new or established patient (D0150), bitewings - four radiographic images (D0274), prophylaxis - adult
(D1110), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional
radiographic image (D0230) provided September 1, 2021, by an OON provider.
You asked the Plan to provide additional payment for the comprehensive oral exam, bitewing x-rays, dental
cleaning, and intraoral x-rays. You say that you cannot afford the cost of the services. The Plan denied your
request. The Plan says the comprehensive exam, bitewing x-rays and dental cleaning were processed correctly
according to OON benefits. Additionally, intraoral x-rays are not covered under your benefits. The
comprehensive exam and dental cleaning were billed twice and so they received a duplicate denial on the
second submission.
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. The Plan contracts say that for
services obtained out-of-network the Plan only pays up to a certain amount. If you choose to see an out-ofnetwork
dentist, you might be billed for charges above what the plan pays, even for services listed as $0
copayment.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that they
covered the full allowed amount for the comprehensive exam, bitewing x-rays and dental cleaning. Since the
services were obtained OON, you are responsible for the difference between what the Plan paid, and the total
cost charged by the OON provider. Therefore, the Plan does not have to provide additional payment for the
comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images
(D0274), and prophylaxis - adult (D1110) provided September 1, 2021, by an OON provider. Though the Plan
offers dental benefits in excess of Medicare coverage, intraoral x-rays are not among those covered services.
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image
(D0220) and intraoral - periapical each additional radiographic image (D0230) provided September 1, 2021, by
an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing provided on December 9, 2020.
You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny coverage of this testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no signed lab order and the claim did not include the DEX Z-code as required by billing rules.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the test is becoming the standard of care for many urologists. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 6, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on March 21, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not authorize an ambulance trip, and you would have arranged transportation yourself. The Plan denied your request. The Plan says the enrollee has 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way ambulance trip.
The enrollee has been asked to pay $236.26, which is less than the $250 copayment for the ambulance transportation. Ambulance transportation falls within the Ambulance Services 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 copayment for ambulance transportation provided on March 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 29, 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 services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an electric recliner (seat lift mechanism)
provided on July 20, 2021. We also decided that the Plan does not have to pay for the sales tax on the recliner
purchased on July 20, 2021.
You asked the Plan to waive the coinsurance for the electric recliner. You also asked the Plan to pay for the
sales tax on the purchase. You say that you were only reimbursed $268.54 because the provider was not
contracted with the Plan. The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for durable medical equipment (DME), including seat lift mechanisms.
We looked at the file and the Medicare's rules. Medicare rules say that sales tax is already calculated in the
allowed amounts paid by the Plan and additional sales tax is not payable.
For DME, your Evidence of Coverage says you are responsible for 20% of the allowed amount, and the Plan is
responsible for 80% of the allowed amount. The allowed amount for the recliner is $366.72. You are
responsible for $73.34, which is 20% of the allowed amount ($366.72 allowed amount x 20% coinsurance =
$73.34). The Plan's share for the recliner is $293.38, which is 80% of the allowed amount ($366.72 allowed
amount x 80% Plan responsibility = $293.38).
However, the file shows that the Plan initially reimbursed you $268.54. The Plan processed your claim twice
by mistake. The Plan reimbursed you again for the recliner on October 13, 2021, in the amount of $293.38. The
Plan stated that they will not recoup the double reimbursement. Therefore, your total reimbursement is
$561.92, which is more than the Plan's 80% responsibility for the electric recliner.
The electric recliner falls within the Durable Medical Equipment (DME) and Related Supplies benefit category.
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 an electric recliner (seat lift mechanism)
provided on July 20, 2021. We also decided that the Plan does not have to pay for the sales tax on the recliner
purchased on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that this procedure is the most appropriate treatment to achieve sustainable long-term relief. You say that the Intracept procedure received FDA clearance and is supported by studies with more than 5 years of follow up post treatment. The Plan denied your request. The Plan says the documentation does not support that this care is needed to treat your condition and does not support the coverage criteria.
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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the destruction of the basivertebral nerve (Intracept Procedure) is experimental for back pain. 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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from July 2,
2020, to August 22, 2020.
You asked the Plan to waive the coinsurance for dialysis services. You say that the coinsurance should be
waived because the enrollee needs monthly dialysis and the bills will add up. The Plan denied your request.
The Plan says the enrollee was charged this coinsurance 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). The enrollee's contract with the Plan clearly says that they must pay
20% coinsurance for Outpatient Dialysis Treatments.
The enrollee has been asked to pay 20% coinsurance for dialysis services. Dialysis services fall within the
Outpatient Dialysis Treatments benefit category. This means that the enrollee has been asked to pay the correct
amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for
dialysis services provided from July 2, 2020, to August 22, 2020.