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

We decided that the Plan does not have to waive the copayment for a comprehensive hearing test performed on August 27, 2021.

You asked the Plan to waive the copayment for the hearing test. You say that you were not advised that you would have another copayment for the second appointment. 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 $35 copayment for each hearing exam in a specialist office. 

You have been asked to pay a $35 copayment for the hearing test. Please note that the office visit and the hearing test have separate copayments per the Plan contract. The hearing test falls within the Hearing 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 a comprehensive hearing test performed on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided September 17, 2021.  You asked the Plan to waive the copayment for the medical eye exam. You say that you feel this should be billed as a routine eye exam. 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 $20 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care.   You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam as billed falls within the Vision 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 the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records document that the enrollee has 5/5 right upper extremity strength with no reported loss of function in the right upper extremity, thus indicating he has adequate right upper extremity strength and function to operate the wheelchair's power options with their own switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on October 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a hospital outpatient clinic visit. You say that the patient represented to you complaining of left eye redness and drainage since morning. You also say that the patient also stated he had a sore throat and yellow crust on his eye and that you are obligated to see patients that come into the Emergency Department and/or Express Care as soon as possible. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.

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 a hospital outpatient clinic visit (G0463) provided on October 6, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar fusion.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs surgery to restore
mobility, and to reduce pain levels. The Plan denied your request. The Plan says that the documentation does
not show a spinal instability.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician
reviewer found that spondylolisthesis is only 1 of 6 possible clinical conditions needed to potentially support
the requested procedure. A condition that supports the requested procedure is segmental instability. There was
not documented segmental instability at L3-4 noted on imaging. However, the provider has noted imaging
suggestive of abnormal facets and scoliosis. The abnormal (likely symptomatic) facet arthropathy on MRI, and
the limited lumbar motion evidences potentially false-negative spine bending films regarding the existence of
segmental spinal instability. There is also longstanding significant spinal stenosis at this level. Instability may
be induced as a result of the need for significantly enhanced, and temporarily destabilizing, intraoperative
decompression given these overall anatomical findings documented. Given the clinical and imaging findings,
and enrollee's documented prior history, the requested lumbar decompression/fusion surgery at L3-4 is
medically reasonable and necessary to treat the enrollee's condition.
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 been met. Therefore, we decided that the Plan has to
pre-approve a lumbar fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on September 1, 2021, to September 2, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you do not feel like you should have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $50 copayment for outpatient basic radiological services/in-network/outpatient hospital visit. 

You have been asked to pay a $50 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient basic radiological services/in-network/outpatient hospital visit 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 ultrasound provided by a participating provider on September 1, 2021, to September 2, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve calcium-sensing receptor (CaSR) gene full gene analysis for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary in order to differentiate primary hyperparathyroidism (PHPT) from benign familial hypercalcemic hypercalciuria (BFHH). The Plan denied your request. The Plan says that this is a tier 2 genetic test and unlikely to impact therapeutic decision-making.

The Plan must follow Medicare rules. Medicare rules say that molecular pathology procedures may be covered when the criteria is 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 the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found given the evaluation to date, and the non-diagnostic work-up coupled with surgical risk in an 86 year old female, it would seem reasonable to do genetic testing to help establish the diagnosis of FHH vs PHPT. 

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 testing have been met. Therefore, we decided that the Plan has to pre-approve calcium-sensing receptor (CaSR) gene full gene analysis for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve epidural steroid injections.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is a lack of documented benefit from a prior epidural steroid injection as well as no documented failure of conservative measures.  The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections can be covered if Medicare 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have chronic low back pain. You were approved for an Epidural Steroid Injection on October 4, 2021, but there is no procedure note or detail of the results. There is no detail of the physical therapy that you have received and progress to date. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257) purchased August 18, 2021.

You asked the Plan to pay for the hearing aids. You say that the provider approved your hearing aids so you assumed they would be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. 

Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257) purchased August 18, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for four additional units of morphometric analysis (88377) provided on August 23, 2021.  You asked the Plan to pay for four additional units of morphometric analysis. You say that this was medically necessary. The Plan denied your request. The Plan says that this exceeds MUE.  The Plan follows Medicare rules. Medicare rules say that Medically Unlikely Edits (MUEs) for HCPCS codes with an MAI of "3" are "per day edits based on clinical benchmarks". MUEs assigned an MAI of "3" are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of "3" during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.   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 pay for our additional units of morphometric analysis. Our reviewer says that this service was performed and medically necessary. Our physician reviewer found this patient underwent bone marrow biopsy and flow cytometry for suspicion of acute myeloid leukemia. She underwent standard testing with morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure. The MUE for 88377 is 5 and the MAI is 3, meaning that units beyond the initial five are payable when it was 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 our additional units of morphometric analysis have been met. Therefore, we decided that the Plan has to pay for four additional units of morphometric analysis (88377) provided on August 23, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for miscellaneous vision service (V2799) deluxe frame (V2025)
progressive lens, per lens (V2781) refraction services (92015) comprehensive eye exam (92004) provided
January 24, 2020.
You asked the Plan to pay for the vision services. You say that you are asking for payment of $100 for the
promise to pay for glasses each year. You are also asking for payment of $85 for the refraction as promised.
The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network
provider.
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 covers these services when the services are provided by an in-network provider.
We looked at the file and the Plan's rules. Enrollee's must receive their vision services from an in-network
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have
not been met. Therefore, we decided that the Plan does not have to pay for miscellaneous vision service
(V2799) deluxe frame (V2025) progressive lens, per lens (V2781) refraction services (92015) comprehensive
eye exam (92004) provided January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genesight testing (81479) provided on June 14, 2021.

You asked the Plan to pay for Genesight testing. You say that this was medically necessary. The Plan denied your request. The Plan says there is not a valid order for this service.

The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. 

We looked at the file and Medicare rules. The physician order in the file is not signed. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical documentation does not support that ongoing physical therapy is needed to
restore or maintain function, or to prevent deterioration.
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 the services. 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 the requested additional therapy is not generally accepted as specific
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this question and
the documentation does not indicate that her functional level requires the unique skills of a professional
therapist to safely and effectively provide treatment, or that the services can be safely and effectively
performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
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 physical therapy services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services and inpatient hospital
care provided from May 1, 2020, to June 15, 2020.
You asked the Plan to waive the copayment for ambulance services and inpatient hospital care. You say that
you do not believe the copayment is correct and would like this claim reprocessed. The Plan denied your
request. The Plan says the copayment processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment per trip for ambulance services and a $295 copayment each day for days 1-6, $0
for additional days for inpatient hospital care.
The enrollee has been asked to pay a total cost share of $2,520 for the 3 ambulance trips ($250 copayment x 3
trips = $750) and 6 days of inpatient hospital care ($295 copayment x 6 days = $1,770). The services provided
fall within the ambulance services and inpatient hospital care benefit category. This means that the enrollee has
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for ambulance services and inpatient hospital care provided from May 1, 2020, to
June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas therapy and nutripharmaceutical vitamin injection provided on August 9, 2021.

You asked the Plan to pay for the Sanexas therapy and nutripharmaceutical vitamin injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas therapy and nutripharmaceutical vitamin injection have not been met. Payment for HCPCS/CPT codes J3411, J3415, J3490, and J7999 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of OK. Therefore, we decided that the Plan does not have to pay for the Sanexas therapy and nutripharmaceutical vitamin injection provided on August 9, 2021.