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

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves with imaging guidance.

You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves with imaging guidance. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical,
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and
necessary when specific criteria are met.

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 destruction of lower or sacral spinal
facet joint nerves with imaging guidance. Our reviewer says that the services are not medically necessary. Our
physician reviewer found the LCD requires 2 separate sets of diagnostic medial branch block (MBBs) where
greater than 80% pain relief is achieved. The enrollee has only had one set. Therefore, 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 destruction of lower or sacral spinal facet joint nerves with imaging guidance
have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of lower or
sacral spinal facet joint nerves with imaging guidance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), single lenses (V2100) and anti-reflective coating (V2750) provided on June 5, 2021.

You asked the Plan to pay for eyeglass deluxe frames, single lenses and anti-reflective coating. You say that you do not agree with the denial on this claim. You also say that you have not made a previous claim in 2021. The Plan denied your request. The Plan says you exceeded the vision allowance benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you have a $300 allowance once per calendar year to use toward the purchase of eyeglasses or contact lenses with a network vision provider. 

We looked at the file and the Plan's rules. The records show you exhausted your vision benefit on June 25, 2021. Additionally, the provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass deluxe frames, single lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), single lenses (V2100) and anti-reflective coating (V2750) provided on June 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on April 21, 2021.

You asked the Plan to waive the copayment for these services. You say that you are dissatisfied with the care you received. The Plan denied your request. The Plan says the copayment was applied 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 $90 copayment for emergency care visits.

Review of the file shows that you received ER services on April 21, 2021. You have been asked to pay a $90 copayment for these services. These services fall within the emergency care 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 the emergency room (ER) services rendered on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307) provided on June 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (80307) provided on June 16, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.

You asked the Plan to pre-approve facet blocks. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 

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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found after review of this case; the enrollee has a documented history of radiculopathy. Therefore, it is not medically necessary or reasonable for this enrollee to have the injections as requested. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a diagnostic mammogram and an ultrasound received on April 29, 2021.
You asked the Plan to waive the copayments for a diagnostic mammogram and an ultrasound. You say that you are entitled to a free mammogram and ultrasound a year. You also say you have had several done in the past two years and were only charged one copayment. The Plan denied your request. The Plan says you have been charged the correct copayment amounts.
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 $130 copayment for x-rays taken at any location other than a physician's office.
Your contract with the Plan also clearly says that enrollees must pay a $125 copayment for other diagnostic procedures and tests at any location other than a physician's office.
While there is no copayment for one screening mammogram every 12 months, you received a diagnostic mammogram. You have been asked to pay a $130 copayment for a diagnostic mammogram. You have also been asked to pay $30.06 for an ultrasound, which is less than your $125 copayment. A diagnostic mammogram and an ultrasound fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammogram and an ultrasound received on April 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine physical therapy (PT) visits, eight home health aide
visits, and eighteen occupational therapy (OT) visits.
You asked the Plan to pre-approve home health services and therapy visits. You say that these services are
medically necessary. The Plan denied your request. The Plan says documentation does not support that these
visits would reasonably improve your functioning. Teaching and education should have occurred during
previous home visits for you to continue care on your own.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or 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 home health services and therapy visits.
Our reviewer says that the requested care is not medically necessary. Our physician reviewer found that there is
no documentation of an acute medical condition requiring the services of a skilled home health nurse.
There is no documentation that skilled therapy services are required beyond what has already been provided.
You are reported to be severely functionally limited, dependent on a power wheelchair for mobility and
dependent for most activities of daily living. Documentation that further therapy beyond what has already been
provided would be reasonably beneficial is lacking in the records. In addition, based on the medical records
provided there is no indication that further skilled services are necessary to treat your illness or injury by a
skilled professional staff. The requested services are 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 home health services and therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve nine physical therapy (PT) visits, eight home health aide
visits, and eighteen occupational therapy (OT) visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on November
8, 2020.

You asked the Plan to waive the copayment for the breast ultrasound. You say that this is a necessary screening
test and should be covered at no charge according to New York state law. The Plan denied your request. The
Plan says you were charged this copayment correctly. The Plan says that only screening mammograms are
covered without cost sharing.

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 $60
copayment for ultrasounds.

You have been asked to pay a $60 copayment for the breast ultrasound. 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. Please note, that the New York law that you referenced in your
appeal letter is not applicable to Medicare or Medicare Advantage Plans.

(You can find this information at https://www.health.ny.gov/diseases/cancer/breast/nys_breast_cancer_faqs.htm). 

Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound you had on November 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 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 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 laboratory services rendered on March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT. You say that the enrollee requires additional PT services. The Plan denied your request. The Plan says additional PT is 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 additional PT. 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 based on the available records, the enrollee has had physical therapy treatments and has refused to participate multiple times. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status within a reasonable period of time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.

You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 36 one-way transportation trips when each one-way trip does not exceed 50 miles. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a new plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of care. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health office visit provided February 16, 2021 to April 14, 2021.

You asked the Plan to pay for the office visit. You say that you are trying to be reimbursed for out of network behavioral health claims. The Plan denied your request. The Plan says this provider has opted out of Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the behavioral health office visit provided February 16, 2021 to April 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy service (90837) provided on March 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy service. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says there was no documented contact with the attending or primary care physician. There is no referring physician listed on the claim.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for individual psychotherapy service (90837) provided on March 26, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colostomy rendered on February 1, 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 44141 is not supported.

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 44141 is colectomy, partial; with skin level cecostomy or colostomy. 

We find that CPT code 44141 is not supported in the medical record. Specifically, there is no documentation of a partial colectomy with skin level cecostomy or colostomy.

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 pay for the colostomy rendered on February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy visits from April 6, 2021, to April 27, 2021.
You asked the Plan to waive the copayment for physical therapy visits. You say that you believe you should only be charged for one copayment. The Plan denied your request. The Plan says the copayment applied 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 each Medicare-covered physical therapy visit.
You have been asked to pay a $90 copayment for six (6) physical therapy visits ($15 x 6). Physical therapy visits fall within the Outpatient Rehabilitation 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 physical therapy visits from April 6, 2021, to April 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on May 27, 2021.

You asked the Plan to waive the copayment for these services. You say that you thought the services would be preventive. The Plan denied your request. The Plan says the copayment was applied 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 $175 copayment for in-network ambulatory surgical center visits.

Review of the file shows that you had a diagnostic colonoscopy on May 27, 2021. The colonoscopy was diagnostic in nature because it was performed for diagnoses of benign neoplasm of the ascending colon and rectosigmoid junction, other hemorrhoids, and removal of tumor polyps. You have been asked to pay a $175 copayment for these services. These services fall within the in-network ambulatory surgical center 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 the outpatient surgical services rendered on May 27, 2021.