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

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that the requested treatment is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested procedure have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty will be considered medically 
reasonable and necessary when a history of unsuccessful appropriate conservative therapy is clearly 
documented in the pre-procedure medical record. 
 
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 total knee arthroplasty. Our reviewer 
says that the requested procedure is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation provided of adequate conservative measures to include 
nonsteroidal anti-inflammatory drugs (NSAIDs) and recent physical therapy. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on May 5,
2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you did not request for this
to be done in the first place. You said that if the provider felt this was necessary, then insurance should cover it
100%. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says
that because the allowed amount for this ultrasound ($93.97) is less than your copayment obligation, you are
responsible for the full allowed 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 $100
copayment for ultrasounds. You have been asked to pay a $100 copayment for the breast ultrasound. This copayment applies regardless of
the reason for this 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 breast ultrasound you
had on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815).

You asked the Plan to pre-approve the PET scan. You say that you feel this should be approved because you are afraid it can be cancer. You have bone cancer in your bone and skin and it's really delicate and tumors are in front of the heart. They need removal as soon as possible. The Plan denied your request. The Plan says further imaging cannot be approved without knowing the outcome of the previous test.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has mediastinal lymphadenopathy measuring up to 1.6 cm that has grown 0.2 cm in about a years-time. Given the slow growth it is unlikely to be a fast-growing malignancy and the yield of PET likely low. Should the PET be negative a biopsy would still be of use to diagnosis nonmalignant causes such as sarcoidosis. The service 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 the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815).
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. It is likely that the enrollee would benefit from more extended therapy, but they refused participation in therapy some days. The necessary care can be provided in another setting.
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. 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 this 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 waive the copayment for an inpatient hospital stay provided from June 10, 2021, to June 15, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because a surgical procedure kept being pushed off. 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 $350 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from June 10, 2021, to June 15, 2021. Therefore, you are responsible to pay a $350 copayment for days 1-5 (June 10, 2021, to June 14, 2021).
The total amount you owe is: $350 (copayment) x 5 (inpatient days) = $1,750. You have been asked to pay the total copayment amount of $1,750 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from June 10, 2021, to June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist physician consultation provided on May 17, 2021.
You asked the Plan to waive the copayment for specialist physician services. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist physician consultation. A specialist physician consultation falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist physician services provided
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external counterpulsation, per treatment session (CPT code G0166).
You asked the Plan to pre-approve the services. You say that you were told that if you do not have the surgery you could die and you are starting to have chest pains again and need the surgery as soon as possible. The Plan denied your request. The Plan says your records tell us that you are able to walk without symptoms, so you do not have Class III angina. The Plan states it is not clear that you are not amenable to surgical intervention. 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 services. Our physician reviewer found the record indicates that you have been recommended for, and is a candidate for, bypass surgery but declines. The elements of the coverage rules are not satisfied. The requested service cannot be 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve external counterpulsation, per treatment session (CPT code G0166).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an outpatient surgical procedure, lab services, and does not have to waive the coinsurance for DME and Medicare Part B drugs provided on June 12, 2020.

You asked the Plan to waive the copayments for an outpatient surgical procedure, lab services, and to waive the coinsurance for DME and Medicare Part B drugs. You say that you feel that you should only owe a surgical copayment and disagree with the additional 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 $325 copayment for each outpatient hospital facility visit, a $20 copayment for laboratory services and 20% coinsurance DME and related supplies and Medicare Part B drugs. 

You had an outpatient surgical procedure on June 12, 2020. Therefore, you are responsible to pay the $325 copayment. 

You received lab services on June 12, 2020. Therefore, you are responsible to pay the $20 copayment. 

You received DME on June 12, 2020. The total allowed amount is $3,327.07 and 20% of that is $665.41. 

You received Medicare Part B drugs on June 12, 2020. The total allowed amount is $35.91 and 20% of that is $7.18. 

The total amount you owe is: $997.60.

You have been asked to pay the total amount of $997.60 for an outpatient surgical procedure, lab services, DME and Medicare Part B drugs. An outpatient surgical procedure, lab services, DME and Medicare Part B drugs 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 copayments for an outpatient surgical procedure, lab services, and does not have to waive the coinsurance for DME and Medicare Part B drugs provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left atrial appendage closure procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have a high enough risk score and is able to take oral anticoagulants. The Plan follows Medicare rules. Medicare rules say that Left Atrial Appendage Closure devices are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that in this case, the record indicates the enrollee has atrial fibrillation. The record indicates that he does not want to take warfarin. However, he is medically able to take warfarin. Second line therapy is not medically required. The elements of the coverage criteria are not satisfied. Therefore, the requested device is not 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left atrial appendage closure procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the anesthesia services. You say that the services are medically necessary. The Plan denied your request. The Plan says the claim originally denied as a non-covered benefit, but not 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 anesthesia services provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you have leg swelling and the post-surgical compression garments being requested are medically necessary. The Plan denied your request. The Plan says the requested item is not covered by Medicare or under your Medicare Advantage contract.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery you had on June 16, 2021.
You asked the Plan to waive the copayment for the cataract surgery. You say that you refused to have the surgery because your blood pressure was high. Since the surgery wasn't completed, you do not think you should pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you went to the facility and were prepped for your surgery. You received numerous injections and anesthesia services. The Plan says that because you received services at the facility, the copayment applies.
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 outpatient surgery. You have been asked to pay a $250 copayment for the cataract surgery. There is no provision in your contract for a waiver of this amount if you decide not to complete the procedure after being prepped and provided anesthesia. 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 cataract surgery you had on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on April 27, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you were not aware that you would owe a copayment for emergency services. 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 $40 copayment for urgently needed services provided by providers other than a primary care physician. You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 copayment for urgently needed services provided on April 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an EGD.
You asked the Plan to pre-approve an EGD. You say that the EGD is medically necessary. The Plan denied
your request. The Plan says EGD is not considered medically needed for reflux unless the member fails a PPI
trial (twice daily dosing for 4 weeks or once daily dosing for 8 weeks). No current trial was noted.
The Plan follows Medicare rules. Medicare rules say that Endoscopy procedures can only be allowed if
abnormal signs or symptoms or known disease are present. 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 EGD. Our reviewer says that an
EGD is not medically necessary. Our physician reviewer found that LCD L35350 criteria consider EGD as
medically necessary when the enrollee has esophageal reflux symptoms or dyspepsia, which are persistent or
recurrent despite appropriate therapy. However, LCD criteria are not met in this case since the enrollee is
taking no appropriate acid suppression treatment despite his endoscopic history of gastroesophageal reflux
disease (GERD).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have
to pre-approve an EGD.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided from January 7, 2021, to March 18, 2021.

You asked the Plan to pay for lab tests. You say that this place of service code is correct because you had someone collecting the sample/specimen at the skilled nursing facility. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the Place of Service (POS) code billed on this claim is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). Medicare rules say that the provider must furnish sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. No records were submitted to support the Place of Service (POS) code billed on this claim. You say that the sample for this testing was taken in a skilled nursing facility setting, in which case the Place of Service (POS) code 81 would not be appropriate for this claim. Without supporting records, you have not furnished sufficient information to justify payment of this claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided from January 7, 2021, to March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that she has been unable to go to meals in the dining room and has had extra nursing services added due to recent falls in the last month. You say that she must continue physical therapy to improve strength, coordination and stamina to reduce risk of injury, and decrease financial burden from extra services. 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 10 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 the patient has had prior therapy of 20 visits and has had instruction on safe transitions and maneuvering. 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 10 additional physical therapy visits have not been