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

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on May 4, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the diagnostic test should have been a preventive measure with a lower copayment. The Plan denied your request. The Plan says the provider verified and billed for a diagnostic test. Therefore, the proper copayment was 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 $150 copayment for outpatient diagnostic tests.
You have been asked to pay a $150 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 a diagnostic colonoscopy provided on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after February 14, 2022.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee no longer meets the coverage criteria for the requested SNF care.
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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 68-year-old male with dementia with Lewy bodies and falls. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after February 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional home health physical therapy visits (G0151).
You asked the Plan to pre-approve 3 additional home health visits. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
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. A doctor must certify the need for home health care services. 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 3 additional home health visits. Our reviewer says that additional home health physical therapy visits are not medically reasonable and necessary in this case. Our physician reviewer found that you do not have documented ongoing home health physical therapy needs. You appear to have reached a plateau in function. You have caregivers available 24/7 for assistance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional home health physical therapy visits (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home health visit provided on May 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a home health visit. You say that the primary care physician sent the referral, so services were provided. The Plan denied your request. The Plan says a non-network physician referred the non-network provider, and no authorization was obtained. Therefore, services cannot be paid for.
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 home health visit provided on May 18, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration services (90471) provided on March 4, 2021.  You asked the Plan to pay for the vaccine and administration. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this vaccine is not covered under the medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine and administration. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and administration services (90471) provided on March 4, 2021.   Benefits for the vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sleep study (95810), provided on April 14, 2021.
You asked the Plan to waive the copayment for a sleep study. You say that the cost share is wrong. 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 $275 sleep study and stress test copay for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $275 sleep study and stress test copay for a sleep study. a sleep study 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 a sleep study (95810), provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 23, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that basically a wellness visit was provided that the enrollee was charged $350.00 for. The Plan denied your request. The Plan says since there was no transport, the ambulance charges are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 23, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The records show that the enrollee refused transport. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious disease testing (81513) provided on August 2, 2021.
You asked the Plan to pay for infectious disease testing. You say that this was medically necessary. The Plan denied your request. The Plan says this exceeds MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 81513 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of infectious disease testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious disease testing (81513) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office 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 office visit provided on June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 13, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim must be submitted to the enrollee's primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar decompression services provided on November 30, 2020.
You asked the Plan to pay for the lumbar decompression services. You say that this claim has been coded correctly and should be reprocessed. The Plan denied your request. The Plan says the claim has an inappropriate modifier.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. In this case, no medical records were provided to corroborate the services as they have been billed. Based on this information, we decided that Medicare rules for coverage of the lumbar decompression services have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar decompression services provided on November 30, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the gait training therapy provided from April 19, 2021, to May 10, 2021.
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The Plan denied your request. The Plan says that the service as an exclusive relationship with procedure code 97530.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
We looked at the file and the rules. We find that CPT code 97116 does not have a status code indicator showing it is a bundled code. The are no procedure-to-procedure (PTP) code edits for CPT code 97116 and 97530. There is no indication that this code pair is unable to be separately payable. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the gait training therapy provided from April 19, 2021, to May 10, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac contractility modulation (CCM) system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T).
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 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. An exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM.
Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug Administration approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 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 insertion or replacement of permanent cardiac contractility modulation (CCM) system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0429), provided on September 4, 2021.
You asked the Plan to waive the copayment for the ambulance service. 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 $250 copayment for ambulances service. You have been asked to pay a $250 copayment for the ambulance service. THis service falls within the ambulances service 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 ambulance service (A0429), provided on
September 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you would benefit from additional therapy, as you are not at your baseline and require more help than your family and home health care can provide. You say that you are weak and need short-term rehabilitation to get stronger. The Plan denied your request. The Plan says the enrollee has not had a change in function warranting daily skilled therapy. The Plan says that the enrollee has no daily skilled nursing needs.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical procedures on the heart (including valves) and great vessels (33340).  You asked the Plan to pre-approve surgical procedures on the heart (including valves) and great vessels. The Plan denied your request. The Plan says based on Medicare guidelines, percutaneous transcatheter closure of the left atrial appendage (Watchman procedure - heart surgery) you and/or your provider is/are requesting does not meet the requirements for approval.  The Plan follows Medicare rules. Medicare rules say that nationally covered indications are a suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants  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 surgical procedures on the heart (including valves) and great vessels. Our reviewer says that surgical procedures on the heart (including valves) and great vessels is not medically necessary. Our physician reviewer found at issue is the medical necessity of implanting a LAAC device in this enrollee in whom there is elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. There is no apparent contraindication to anticoagulation. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this enrollee's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical procedures on the heart (including valves) and great vessels have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical procedures on the heart (including valves) and great vessels (33340).