Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675), and segmental gradient pressure pneumatic appliance (E0673), provided on April 14, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675), and segmental gradient pressure pneumatic appliance (E0673), provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (83880, G0463, 80047, 85014) provided on August 12, 2021, by an OON provider.  You asked the Plan to pay for laboratory services. You say that you received the orders from the physician's office, but nothing about authorization. You also say that after reviewing the claim, you found that this service requires an authorization, which was not obtained prior to testing. The Plan denied your request. The Plan says the rendering provider is a non-participating provider and there is no referring provider involved in these services. The Plan also says that they did not authorize any services for this provider or this facility. 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 laboratory services (83880, G0463, 80047, 85014) provided on August 12, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for cardiac catheterization services provided on June 10, 2021.  You asked the Plan to waive the coinsurance for cardiac catheterization. You say that these charges should be covered by the Plan. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.  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 40% coinsurance for out-of-network diagnostic procedures at an outpatient hospital. The allowed amount of the claim is $922.87, resulting in a coinsurance amount of $369.15.  You have been asked to pay 40% coinsurance for cardiac catheterization. Cardiac catheterization falls 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 coinsurance for cardiac catheterization services provided on June 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the binocular microscopy (92504), provided on July 2, 2021.  You asked the Plan to waive the copayment for the binocular microscopy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $25 non-radiological diagnostic test copay for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   You have been asked to pay a $25 non-radiological diagnostic test copay for the binocular microscopy. the binocular microscopy falls 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 copayment for the binocular microscopy (92504), provided on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neurovascular pedicle flap (15750) provided on September 13, 2021.  You asked the Plan to pay for the neurovascular pedicle flap. You say that this was correctly coded as supported in the medical records. The Plan denied your request. The Plan says the documentation does not support the claim as billed.  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 15750 is Flap; neurovascular pedicle.  We asked our coder 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 the neurovascular pedicle flap. Our reviewer says that the documentation does not support payment for the claim as billed. Our reviewer found the medical records provided do not include documentation to validate that a neurovascular pedicle flap was performed on September 13, 2021; therefore, this procedure cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neurovascular pedicle flap have not been met. Therefore, we decided that the Plan does not have to pay for the neurovascular pedicle flap (15750) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a home ventilator, any type, used with non-invasive interface (E0466)  You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met as it is not medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our reviewer says that this is medically reasonable and necessary for the enrollee's condition. Our physician reviewer found a home ventilator is medically necessary for this patient.  The diagnosis is amyotrophic lateral sclerosis, a neuromuscular disease resulting in death from respiratory failure unless supported with a ventilator. Bilevel positive airway pressure (BiPAP) is insufficient because he will eventually become completely dependent on the ventilator, and interruption in support could quickly lead to death. Battery backup is needed. The potential for sip and puff ventilation is needed. Medicare covers a ventilator for this diagnosis.  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 home ventilator have been met. Therefore, we decided that the Plan has to pre-approve a home ventilator, any type, used with non-invasive interface (E0466)   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, zoledronic acid.  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 Prolia. Our reviewer says that the requested drug, Prolia, is not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee has tried and failed the required drug, zoledronic acid. The reviewer also found that the documentation does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transfer to 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 you are receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services you need are offered at the IRF and transfer to a SNF for inpatient skilled rehabilitation services 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 are ambulating household distances. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve transfer to SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 5, 2021, by an OON provider.  You asked the Plan to pay for a specialist office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the member received services from an out of network provider. The Plan also says that this member does not have out of network coverage for services determined to be non-urgent/emergent.  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 specialist office visit (99213) provided on May 5, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve these services. You say that this is a safer alternative to a laminectomy. The Plan denied your request. The Plan says that this service is considered experimental and investigational.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total knee replacement surgery.  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 the documentation fails to indicate that the member is a surgical candidate for knee replacement surgery.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. It was stated at the evaluation that you are not a good candidate for surgery. Also noted was that a total knee replacement was not recommended by the treating provider or the second opinion provider. Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Imaging studies have not been provided to corroborate osteoarthritis of the right knee. There is limited published, large-scale, long-term peer-reviewed literature that shows the requested surgery to be an effective and/or safe treatment for the noted pathology in this clinical scenario. Our physician reviewer found that your condition does not meet criteria for coverage of 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 total knee replacement surgery.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the procedure (C9606) performed from January 15, 2021, to January 16, 2021.  You asked the Plan to pay for inpatient-only services. The Plan denied your request. The Plan says this is an inpatient-only procedure.  The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.   The service at issue in this appeal was billed with CPT code C9606. This code is listed with a status indicator of "C" on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the procedure (C9606) performed from January 15, 2021, to January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 11, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider is not a specialist and you cannot afford the charge. 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 $40 copayment for provider and professional services received in a specialist office.   Please note that obstetrician-gynecologists are considered specialists by definition. Therefore, you have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit 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 a specialist office visit provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye exam appointment (99214) provided on October 13, 2021.  You asked the Plan to waive the copayment for the eye exam. You say that you thought this was a routine eye exam and would be provided with a $0 copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $30 copayment for per visit for exams to diagnose and treat diseases and conditions of the eye.    You have been asked to pay a $30 copayment for the eye exam. The medical records provided indicate that the appointment and exam in question were provided as a follow-up visit for your cataract surgery. Therefore, the eye exam falls within the exams to diagnose and treat diseases and conditions of the eye 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 eye exam appointment (99214) provided on October 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider.  You asked the Plan to pre-approve SNF care. You say that you are in danger to fall and you are in need of treatment medication, Meroquiden. You state you are getting medication through intravenous (IV) twice a day. The Plan denied your request. The Plan says the medical record received did not show that you have an emergent or urgent medical condition or are in need of specialized service.  Th Plan states there are in-network skilled nursing facilities within a reasonable distance from your location that can provide this service/item.  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 had a daily skilled need, as evidenced by your need for daily IV antibiotics. However, the need was known prior to your admission, making it neither emergent nor urgent. There is no evidence to support that the required care was not available in-network. As such, the provision of care at an OON facility is/was not medically necessary or reasonable.  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 to be provided by an OON provider.