Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a tendon sheath injection, podiatry services and does not have to waive the coinsurance for a Medicare Part B drug injection provided on May 24, 2021.
You asked the Plan to waive the copayments for a tendon sheath injection, podiatry services and to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you 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). Your contract with the Plan clearly says that you must pay a $25 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $40 copayment for podiatry services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a tendon sheath injection on May 24, 2021. Therefore, you are responsible to pay the $25 copayment. You received podiatry services on May 24, 2021. Therefore, you are responsible to pay the $40 copayment. You received a Medicare Part B drug on May 24, 2021. The total allowed amount is $1.29 and 20% of that is $.26. The total amount you owe is: $65.26. You have been asked to pay the total amount of $65.26 for a tendon sheath injection, podiatry services and a Medicare Part B drug injection. A tendon sheath injection falls within the physician/practitioner services, including doctor's office visits benefit category. Podiatry services fall within the podiatry services benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a tendon sheath injection, podiatry services and does not have to waive the coinsurance for a Medicare Part B drug injection provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care from October 9, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are still necessary for this enrollee, who is still experiencing suicidal ideation and will likely self-harm at this point. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this level of care and can continue mental health services in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that continuation of the inpatient psychiatric services is not medically necessary. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on September 16, 2021 with Major Depressive Disorder, Recurrent, Severe without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. The enrollee was compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 9, 2021, forward and could have been treated in a lesser restrictive setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care from October 9, 2021, onward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this
service is not valid for Medicare purposes.
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 S9328 is home infusion therapy, per diem. We find that
CPT code S9328 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and
payment for, these services. 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 home
infusion therapy services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria for the requested device have not been met.
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator requires a covered indication as specified 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 a spinal cord stimulator. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 90-year-old man who has chronic low back pain. His magnetic resonance imaging scan shows multi-level degenerative disc and facet changes as well as severe spinal stenosis. He has had 3 Epidural steroid injections without sustained relief. He has tried home exercise, stretching, ice, heat and physical therapy. In this case, the patient does not have an evidence-based indication for a spinal cord stimulator trial. The request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you were not aware of the requirement of obtaining a prior authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your
request is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We looked at the file and Medicare rules. The file shows that the enrollee previously received radiofrequency
ablation services in the lumbar region on February 8, 2021, March 8, 2021, and September 30, 2021. For each
covered spinal region, no more than two radiofrequency sessions will be reimbursed per rolling 12 months.
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 radiofrequency ablation services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and to waive the copayment for the administration provided on May 18, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayment for the administration. You say that you cannot afford the charges and feel that they are too high for an injection. The Plan denied your request. The Plan says the claims were processed correctly and you 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). Your contract with the Plan clearly says that you must pay a $395 copayment for each non-surgical visit to an outpatient visit and 20% coinsurance.
You received Medicare Part B drugs on May 18, 2021. The total allowed amount is $3,171.15 and 20% of that is $634.23. You received the administration of Medicare Part B drugs at an outpatient hospital facility on May 18, 2021. Therefore, you are responsible to pay $246.74, which is less than the $395 copayment. The total amount you owe is: $880.97. You have been asked to pay $880.97 for Medicare Part B drugs and the administration. Medicare Part B drugs and the administration fall within the outpatient hospital services 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 Medicare Part B drugs and to waive the copayment for the administration provided on May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
You asked the Plan to pre-approve Supartz. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Supartz. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that enrollee is a 69-year-old female with bilateral knee osteoarthritis. The provider is requesting an intra-articular injection with Supartz. The enrollee has tried and failed pharmacologic therapy including cortisone injections, physical therapy and medication management. The enrollee has not trialed viscosupplemental treatments such as Euflexxa and Synvsic/Synvisc-One. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Supartz is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis.
You asked the Plan to pre-approve Lucentis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Lucentis. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has wet age related macular degeneration. 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
such as Avastin, Mvasi or Zirabev. 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 Lucentis have not been met. Therefore, we decided that the Plan does not have
to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (92014).
You asked the Plan to pre-approve an office visit with an ophthalmologist. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is a non-covered vision exam.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
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 an office visit with an ophthalmologist. Our reviewer says that the requested service is not covered. Our physician reviewer found that the record indicates that you were seen by an out of network ophthalmologist for vision services for diplopia and strabismus. You are not being treated for surgery that removed a lens. We looked at this physician's review, the file, and Medicare rules. The requested service is considered routine vision care. Therefore, we decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (92014).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97116 and 97110) provided on 
July 1, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the provided records do not support that 
the Physical Therapist was physically present. 
 
The Plan must follow Medicare rules. Medicare rules say that a physical therapist must supervise PTAs. 
 
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 record does not indicate that the 
Physical Therapist was on site and supervising the PTA. Therefore, we decided that the Plan does not have to 
pay for the physical therapy services (97116 and 97110) provided on July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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 May 21, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you don't understand why the x-rays are not
covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic
image (D0230) provided May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 20, 2021.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 additional physical therapy visits.
You asked the Plan to pre-approve 17 additional physical therapy visits. You say that the provider said you
were making progress with physical therapy. The Plan denied your request. The Plan says additional visits are
not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 17 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy and have
been instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist
are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 17 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 17 additional physical therapy visits
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
February 26, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that your doctor called for the
ambulance because your heart rate was low. You say that you should be reimbursed for this copayment. 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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the transport. 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 ambulance services you
received on February 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on June 3, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service this claim must be submitted
to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for medical services provided to the enrollee on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 6, 2021, to April 9, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not believe you were admitted for that many days as you spent the night in the emergency room. The Plan denied your request. The Plan says the claims were processed correctly and you 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). Your contract with the Plan clearly says that you must pay a $250 copayment for days 1-3 for inpatient hospital coverage. The medical records show that you had an inpatient hospital stay from April 6, 2021, to April 9, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-3 (April 6, 2021, to April 8, 2021). The
total amount you owe is: $250 (copayment) x 3 (inpatient days) = $750. You have been asked to pay the total copayment amount of $750 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital coverage 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 an inpatient hospital stay provided from April 6, 2021, to April 9, 2021.