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

We decided that the Plan does not have to waive the $300 copayment for outpatient surgery provided on January 29, 2021.
You asked the Plan to waive this copayment. You say that this surgery was due to a previous physician error and you should not have to pay the copayment., The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement.
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 $300 copayment for outpatient surgical or hospital services. 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 $300 copayment for outpatient surgery provided on January 29, 2021 by the provider.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for services billed under code 64635-LT.
You asked the Plan to pay for this service. The Plan denied your request. The Plan says code 64635-LT (2) was not billed correctly. The Plan says that code 64635 has a Medically Unlikely Edits (MUE) value of "1" and the MAI indicator is "2" and billed 2 units. Per physician fee schedule, the bilateral surgery indicator is "1". The guidelines stated if the bilateral surgery indicator is "1" then it must be reported with "1" unit of service and modifier 50.
The Plan must follow Medicare rules. Medicare rules say providers must report services with the appropriate codes and when applicable the appropriate modifier. In this case, this claim cannot be paid as billed due to an issue with the number of units billed and the omission of the required modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on July 20, 2021 and billed under code 64635-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded as 82310, 82728, 83540, 83550, 83970, 84100 provided May 5, 2021.
You asked the Plan to pay for the laboratory services. You say that there is no contractual agreement in place which indicates that the CPT codes billed are included in the dialysis rate. It is your position these CPT codes need to be reprocessed for payment due. The Plan denied your request. The Plan says All laboratory services furnished to individuals for the treatment of ESRD are included in the ESRD PPS as Part B services and are not paid separately.
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, we have confirmed that the dialysis laboratory services is included in the ESRD facility claim. Payment to you for these services is the responsibility of the facility. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 82310, 82728, 83540, 83550, 83970, 84100 provided May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure you had on April 13, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that this procedure was needed as a result of an error in December 2020. 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 $300 copayment each visit for outpatient surgery. You have been asked to pay a $300 copayment each visit for the outpatient surgery. This copayment applies regardless of the reason for the procedure. 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 surgical procedure you had on April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been taking Eliquis successfully since 2018. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on
February 8, 2021, by an out-of-network provider.
You asked the Plan to pay for outpatient mental health services. You say that you have obtained authorization for these services starting from June 6, 2021, but services prior to this date should be reconsidered for payment. 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 outpatient mental health services provided on February 8, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess capsules.
You asked the Plan to pre-approve Linzess capsules. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says Linzess capsules are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess capsules.
Benefits for Linzess capsules may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says the records received do not indicate that the enrollee has an emergent or urgent medical condition or are in need of specialized service(s) that are not available in the network. There are in-network provider(s) within a reasonable distance from the enrollee's location that can provide this 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is indicated for treatment of severe reactive hypoglycemia. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of diabetes mellitus.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a
diagnosis of diabetes mellitus. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on
August 31, 2021 and billed under code 17311.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request.
The Plan says code 17311 and pathology services code 88305 must be reported by a single physician who
performs both the surgery and pathologic examination of the specimen. A review of the claim history shows
services were performed by different providers. Services may be reported separately using modifier 59 or -
X{SU}, or 58 to distinguish the diagnostic biopsy from the definitive Mohs surgery. The appropriate modifier
was not billed. The plan will accept a submission of a corrected claim to consider services for payment
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when appropriate the required modifiers.
In this case, this claim cannot be paid as billed due to the omission of the required modifier. Based on this
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we
decided that the Plan does not have to pay for physician services provided to the enrollee on August 31, 2021
and billed under code 17311
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services for additional weaning that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 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.
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 enrollee is losing her ability to function normally and needs IRF level of care. The Plan denied your request. The Plan says Under Medicare, the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
May 13, 2020 to July 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there was no documentation of the DRG billed for the hospitalization. The review has determined that the records do not support the DRG and diagnosis codes used in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 13, 2020 to July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Siliq for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Siliq for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $120 copayment charged for emergency room services provided on April 8, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says the provider billed the Plan $1,933.00. The Plan paid this claim except for the contract copayment of $120.
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 $120 copayment for emergency room services. 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 $120 copayment charged for emergency room services provided on April 8, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Monovisc injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the plan can require a trial of a preferred drug before coverage another non-preferred drug.
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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that these drugs would likely be less effective and/or likely to 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Monovisc injection.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on
May 25, 2021 to June 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you were not able to find a provider in your area and none were listed in your area, so you had to find an out of network provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 individual psychotherapy (90834) provided on May 25, 2021 to June 29, 2021 by an out-of-network (OON) provider.