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

We decided that the Plan does not have to waive the coinsurance for the betamethasone acetate injection you received on August 30, 2021.
You asked the Plan to waive the coinsurance for the betamethasone acetate injection. You say that you think the Plan should pay for this and you don't agree with the charge. The Plan denied your request. The Plan says you were 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the betamethasone acetate injection. The betamethasone acetate injection falls within the Medicare Part B 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 the betamethasone acetate injection you received on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lithium ion battery charger (L7368).
You asked the Plan to pre-approve the charger. You say that this is medically necessary. The Plan denied your request. The Plan says a separate request for this code is denied as unbundled.
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 code L7368 is a column II code to column I code L5856. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pre-approve a lithium ion battery charger (L7368).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the hip you had on August 24, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you think the plan should pay for this and you do not agree with the charge. 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 $15 copayment for x-rays. You have been asked to pay a $15 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 of the hip you had on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on June 1, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra.
You asked the Plan to pre-approve Actemra. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Actemra. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the review indicates that the review
indicates that the documentation does not support that the Actemra is medically reasonable or necessary for the
enrollee. The documentation does not support that the Actemra is safe and effective 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 Actemra have not been met. Therefore, we decided that the Plan does not have
to pre-approve Actemra.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied
your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 spinal surgery. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee had a prior radiofrequency ablation (RFA) at these levels. Repeat diagnostic medial
branch block (MBB) demonstrated greater than 80% pain relief. The repeat of a prior level RFA where there is
more than 6 months of pain relief is medically reasonable and 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 spinal surgery have been met. Therefore, we decided that the Plan has to preapprove
spinal surgery.
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 pay for the chest x-ray rendered on August 13, 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 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray , single view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on August 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy (PT) services with a non-participating provider while the enrollee is in Florida.
You asked the Plan to pre-approve the PT services. You say that after the enrollee's accident while at the post-operative appointment, the doctor advised that the enrollee could not fly home to New York. You also say that the enrollee is currently living with you, in Florida, and needs to be around family that can provide the full support he needs to rehabilitate. The Plan denied your request. The Plan says that the enrollee must use plan providers in order for services to be covered. The Plan also says that the enrollee does not have out-of-network benefits.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 PT services. Our reviewer says that the criteria for out-of-area urgent PT services are met in this case. Our physician reviewer found the enrollee could not have foreseen falling and requiring surgery. Our reviewer found that the documentation supports that the enrollee's surgery was medically necessary, and it follows that postoperative PT would also be medically reasonable and necessary. Our physician reviewer also found that it would not be medically reasonable to delay PT services until the enrollee returns to his service area. It is medically reasonable and necessary for evaluation and management by PT to ensure that the enrollee is functionally stable. 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 PT services have been met. Therefore, we decided that the Plan has to pre-approve physical therapy (PT) services with a non-participating provider while the enrollee is in Florida.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hereditary Assessment for Cardiac Conditions testing rendered on June 3, 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Hereditary Assessment for Cardiac Conditions testing rendered on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of chiropractic care.
You asked the Plan to pre-approve the continuation of chiropractic care. You say that this care continues to be medically necessary. The Plan denied your request. The Plan says no further clinical benefit can be expected from ongoing chiropractic care
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 continuation of chiropractic care. Our reviewer says that the continuation of chiropractic care is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the record indicates that the enrollee has been receiving continuous chiropractic services. The submitted medical records are insufficient to establish that the requested services are not maintenance therapy. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 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 continuation of chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of chiropractic care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin biopsy procedure you had at an outpatient hospital facility on August 17, 2021.
You asked the Plan to waive the copayment for the skin biopsy procedure. You say that you are being billed a copayment each time you are seen for the same issue. You believe the copayment should apply once to the whole process, not every time you enter the building. 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 $100 copayment for surgery or other services at an outpatient hospital facility. You have been asked to pay a $100 copayment for the skin biopsy procedure.
The skin biopsy procedure falls within the surgery or other services at an outpatient hospital facility benefit category. This copayment is applied each time you receive a service. 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 skin biopsy procedure you had at an outpatient hospital facility on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on September 1, 2021.
You asked the Plan to pay for the incomplete endodontic therapy. You say that you feel the cost of this service was not warranted for just receiving a filling and not repairing the root canal. The Plan denied your request. The Plan says this service is not covered.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen testing provided on September 21, 2020.
You asked the Plan to pay for the pathogen testing. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says an appropriate POS code was not reported for this claim.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen testing provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for teeth # 22 and 27.
You asked the Plan to pre-approve the dental services. You say that you need these services to be covered. The Plan denied your request. The Plan says the surgical extraction of teeth # 22 and 27 are not medically necessary.
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 covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the surgical extractions are not medically necessary. Our physician reviewer found a surgical extraction is indicated when bone removal and/or sectioning of the tooth is required. The provided documentation indicates that the coronal aspects of these teeth are intact allowing for removal via forceps and/or elevation. Therefore, the reviewer found that teeth # 22 and 27 do not meet the criteria for coverage for surgical extractions.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file indicates that removal and/or sectioning of the tooth is not required for the requested extractions. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) for teeth # 22 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and periodontal maintenance (D4910) provided on May 10, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the comprehensive oral evaluation and periodontal maintenance. You say that you were not aware that your Plan included a clause denoting that services rendered by providers that did not accept Medicare would not be covered. You also say that it was your understanding you had $1,500.00 coverage for dental insurance. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective May 10, 2016, to May 10, 2022.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and periodontal maintenance (D4910) provided on May 10, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377)
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for these additional accessories. The provided records document that the enrollee has 3/5 bilateral upper extremity strength and normal upper extremity range of motion and is independent with feeding. The documentation indicates that the enrollee has adequate upper extremity strength, function, and range of motion to operate the wheelchair's power options with their own switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377)
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require intensive therapies, consisting of at least 3 hours of therapy per
day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and
low intensity setting such as in a skilled nursing facility or in-home with therapies.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing provided on August 6, 2021.
You asked the Plan to pay for the testing services. You say that the test can be used to identify therapy options.
The Plan denied your request. The Plan says the results will not be sued to direct the plan of care.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under
certain medical indications.
The file shows that FoundationOne testing was provided. In this case, there were no recent medical records
provided to show that the results of testing will impact clinical management to improve the enrollee's outcome.
The records did not show that the enrollee was seeking further cancer treatment. Based on this information, we
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that
the Plan does not have to pay for the next generation sequencing provided on August 6, 2021.