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

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (CPT code
20939) for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of
spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 service.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve
bone marrow aspiration for bone grafting (CPT code 20939) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 20, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for March 20, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 28, 2021, by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for the drug testing. You say that 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this drug is not medically necessary.

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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of an inadequate response to conservative therapies. The documentation does not support that Euflexxa is medically reasonable or necessary for this enrollee. The documentation does not support that the Euflexxa is safe and effective for this 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica 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 Lyrica 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on August 7, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the higher charges because you went to an urgent care facility. 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 $120 copayment for emergency care. The medical records show that you received emergency care at an outpatient hospital facility on August 7, 2020. Therefore, you are responsible to pay the allowed amount of $112.66, which is less than the $120 copayment. You have been asked to pay $112.66 for emergency care. Emergency care falls within the emergency care 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 emergency care provided on August 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Northera.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Northera.

Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 25, 2021.
You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has urinary urge incontinence. She has not tried and failed the Plan's required drug, Myrbetriq. The records do not show that the required drug would be contraindicated or less effective; therefore, Botox is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from May 3, 2021, to May 19, 2021.

You asked the Plan to waive the deductible for an inpatient hospital stay. You say that you cannot afford 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. Your contract with the Plan says that there is a $300 deductible which applies to inpatient hospital care. You will not pay more than $300 after the plan deductible for inpatient hospital covered services in a calendar year. 

You had an inpatient hospital stay from May 3, 2021, to May 19, 2021. The record shows that there are no other inpatient hospital stays on record for 2021. Therefore, you are responsible to pay the $300 deductible. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was received on May 3, 2021 to May 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from May 3, 2021, to May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous passive motion device for use other than knee (E0936) provided on January 1 to January 9, 2021.

You asked the Plan to pay for a continuous passive motion device for use other than knee. You say that the doctor sent the item at issue to your house for use after a rotator cuff surgery for your shoulder and arm. You feel the item should be covered by your insurance. The Plan denied your request. The Plan says the item at issue is not a covered benefit as prescribed.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for a continuous passive motion device for use other than knee (E0936) provided on January 1 to January 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on June 1, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on June 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on July 2, 2020, to July 31, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the services are 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on July 2, 2020, to July 31, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the genetic testing services you received on April 1, 2021.

You asked the Plan to waive the coinsurance for the genetic testing services. You say that the doctor sent your sample for genetic testing without your consent, so you shouldn't have to pay this. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that it confirmed in your medical records that you were talked to by this doctor about this genetic testing and you verbalized understanding of this testing.

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 molecular or predisposition genetic testing.

You have been asked to pay 20% coinsurance for the genetic testing services. 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 genetic testing services you received on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received on May 12, 2021.

You asked the Plan to pay for the office visit. You say that you would rather attempt pain management than surgery. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit received on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received from June 5, 2021, to June 7, 2021.

You asked the Plan to waive the copayment for the ER services. You say that you went to the ER via ambulance on June 5, 2021 and were not discharged until June 7, 2021. You said that the doctor told you that you were being admitted. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan stated that they confirmed that you only owe the $90 copayment to the hospital, not the $200 that you noted in your appeal.

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 $90 copayment for emergency room visits.

You have been asked to pay a $90 copayment for the ER services. Billing records confirm that you were not admitted to the hospital. Instead, you were kept in observation status, which is an outpatient (non-admission) status. That is why the copayment applies. 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 emergency room (ER) services you received from June 5, 2021, to June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of nail(s) services coded 11721 and the paring or cutting of benign hyperkeratotic lesion coded 11055 provided on February 12, 2021.

You asked the Plan to pay for the debridement of nail(s) services and the paring or cutting of benign hyperkeratotic lesion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 11721 and 11055 is not supported in the medical record. Specifically, code 11721 was already processed and paid to the same provider for the same date of service. Code 11055 was not billed with a valid diagnosis. Based on this information, we decided that Medicare rules for coverage of the debridement of nail(s) services and the paring or cutting of benign hyperkeratotic lesion have not been met. Therefore, we decided that the Plan does not have to pay for the debridement of nail(s) services coded 11721 and the paring or cutting of benign hyperkeratotic lesion coded 11055 provided on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery with allograft (20930) autograft
(20936) and arthrodesis (22612).

You asked the Plan to pre-approve the spinal surgery. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation does not show that the
member is not an active smoker or that a spinal fusion has been approved.

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 spinal surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found detailed documentation is not evident regarding dynamic flexion/extension films to
potentially assess the amount of movement (instability) at the requested surgical level. Detailed documentation
is not evident regarding potential impending/inevitable temporary intra-operative instability. In addition, she is
noted to be a current, daily smoker. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of this request as an exception to guidelines.

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 spinal surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve the spinal surgery with allograft (20930) autograft (20936) and arthrodesis (22612).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.