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

We decided that the Plan does not have to pay for an x-ray (74250) provided on December 7, 2020.
You asked the Plan to pay for an x-ray. You say that this service should not be bundled. The Plan denied your request. The Plan says this is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74250 has a bundled relationship with code 74240 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (74250) provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Criteria for IRF admission have not been met. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 14, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is also out-of-network.
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 lab work provided on April 14, 2021 by an out-of-network
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening tests provided on July 19, 2020. You asked the Plan to pay for screening tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because predictive screening testing is not a Medicare benefit.
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for screening tests provided on July 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.
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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis and neurogenic claudication. The record indicates that imaging has demonstrated multi-level degenerative disc disease and mild to moderate spinal stenosis at L4-L5, the level requested for treatment. The record does not indicate that the enrollee is not indicated for surgery at more than two levels. The record does not indicate that the enrollee experiences relief in flexion. The elements of the coverage criteria 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of mechanical traction provided on April 14, 2021.
You asked the Plan to pay for application of mechanical traction (97012). You say that Medicare has paid for this service for over 10 years. 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for application of mechanical traction provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion or replacement of a cranial neurostimulator provided on April 26, 2021.
You asked the Plan to waive the coinsurance for the insertion or replacement of a cranial neurostimulator. You say that you feel that the inpatient hospital copayment should apply instead. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the insertion or replacement of a cranial neurostimulator at an outpatient hospital facility on April 26, 2021. The total allowed amount is $29,409.19 and 20% of that is $5,881.84. You have been asked to pay the total coinsurance amount of $5,881.84 for the insertion or replacement of a cranial neurostimulator. The insertion or replacement of a cranial neurostimulator falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the insertion or replacement of a cranial neurostimulator provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted with hypoxic respiratory failure from COVID-19 pneumonia. The enrollee returned to the intensive care unit due to anemia for acute blood loss. The enrollee is not clinically stable. The enrollee continues to receive acute care services and these services have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for catheter placement in a coronary artery. We
decided that the Plan does not have to reduce the cost-sharing charges for catheter placement in a coronary
artery to the amount you requested. You asked the Plan to reduce the cost-sharing charges for catheter placement in a coronary artery. You say that
you thought that you would not be charged for any coronavirus related services. The Plan says that the claims
were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for catheter placement in a coronary
artery from $1,060.93 to $12.
The plan says that you must pay $1,060.93 for catheter placement in a coronary artery. However, catheter
placement in coronary artery is considered an outpatient diagnostic procedure or test. Therefore, you cannot be
asked to pay more than $12 according to your contract with the Plan. Therefore, we decided that the Plan has to
reduce the cost-sharing charges for catheter placement in a coronary artery from $1,060.93 to $12.
We also decided that the Plan does not have to waive the $12 copayment for catheter placement in a
coronary artery.
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 $12
copayment for diagnostic tests and procedures. Therefore, we decided that the Plan does not have to waive the
copayment for catheter placement in a coronary artery.
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 a nerve stimulator placement (64590).
You asked the Plan to pre-approve the nerve stimulator placement. You say that the stimulator is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 nerve stimulator placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the file indicates that the enrollee has urge incontinence. No medical information is available for review. The elements off the coverage criteria are not satisfied. 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 nerve stimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve stimulator placement (64590).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on April 14, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and should have been provided at no charge to you. The Plan denied your request. The Plan says the copayment for this service was applied correctly. Documentation shows that this was not a routine eye exam and was a consultation for your cataracts.
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 $10 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye. You have been asked to pay a $10 copayment for the eye exam. The eye exam was billed as a medical service and included a medical diagnosis relating to cataracts. A routine eye exam is performed to verify changes in vision and evaluate the need for glasses or contacts and is not related to any medical diagnosis or treatment. Therefore, this eye exam falls within the outpatient physician services for the diagnosis and treatment of diseases and injuries 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 (92014) provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (75571).
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the imaging is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is covered for patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms. 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 myocardial perfusion imaging. Our reviewer says that the requested testing is not medically necessary. Our physician reviewer found the record indicates that the enrollee has coronary artery disease but does not state that the enrollee has new, recurrent, or worsening cardiac symptoms. The elements of the coverage criteria are not satisfied. 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 myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient psychiatric services from September 7,
2021, forward.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the inpatient psychiatric care
is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the
inpatient psychiatric services requested do not meet the requirements for approval beginning September 7,
2021.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. 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 inpatient psychiatric services. Our
reviewer says that the inpatient psychiatric services starting September 7, 2021, are not medically necessary.
Our physician reviewer found that it did not appear medically necessary and reasonable to have psychiatric
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question
as she did not have dangerousness to self or others but was compliant with her treatment. This enrollee did not
appear to require inpatient mental health treatment beyond the date in question as she was not a danger to
herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment.
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the
services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond
the date in question. Based upon review the records provided for the admission of this enrollee does not meet
the criteria for continued acute inpatient mental health treatment for the dates in question of September 7, 2021
forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory
or, visual hallucinations and was cooperative/compliant with treatment while not showing any threats the
safety.
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 inpatient psychiatric services have not been met. Therefore, we decided that
the Plan does not have to pre-approve the inpatient psychiatric services from September 7, 2021, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Truxima first.
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 Rituxan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has B cell lymphoma. The enrollee previously was on Rituxan but is not receiving it for several years. The requested medication is considered a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 16, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is also out-of-network.
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 lab work provided on April 16, 2021 by an out-ofnetwork
(OON) provider.