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

We decided that the Plan does not have to pre-approve the TMS to be provided by an OON provider.
You asked the Plan to pre-approve the TMS. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary, and the provider is 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 TMS. Our reviewer says that the service is not medically necessary. Our
physician reviewer found although you have responded to TMS in the past, the record shows there is no
documentation of resistance to treatment with psychopharmacologic agents in the current depressive episode to
meet criteria for TMS. The record shows the provider is not a part of the insurance network.
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 TMS have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve the TMS. Therefore, we decided that the Plan does not
have to pre-approve the TMS to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Genicular Radiofrequency ablation (64624).  You asked the Plan to pre-approve Genicular Radiofrequency ablation (64624). You say that the requested Genicular Radiofrequency ablation (64624) is medically necessary. The Plan denied your request. The Plan says the requested Genicular Radiofrequency ablation (64624) 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 Genicular Radiofrequency ablation (64624). Our reviewer says that the requested Genicular Radiofrequency ablation (64624) is not medically necessary. Our physician reviewer found the enrollee has chronic right knee pain. She takes Flexeril, Zanaflex, Gabapentin and Lyrica for pain. She had a diagnostic genicular nerve block on October 12, 2021, and obtained 95% pain relief for 2 weeks. The request is for radiofrequency ablation (RFA) of the Right Genicular nerves. This procedure is considered experimental/investigational at this time.  Therefore, the request is deemed not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Genicular Radiofrequency ablation (64624) have not been met. Therefore, we decided that the Plan does not have to pre-approve Genicular Radiofrequency ablation (64624).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve percutaneous sacroiliac (SI) joint fusion.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that SI joint fusion is covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of percutaneous SI joint fusion remains experimental for the treatment of sacroilitis and degenerative back pain treatment. The surgery is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous sacroiliac (SI) joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for hearing aids provided on September 7, 2021.  You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan says the claim processed correctly with the maximum $100 yearly allowance.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan has processed and paid the claim correctly with the maximum $100 yearly allowance for the hearing aids. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency ablation.
You asked the Plan to pre-approve lumbar/sacral facet joint radiofrequency ablation. You say that the requested lumbar/sacral facet joint radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested lumbar/sacral facet joint radiofrequency ablation.
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 lumbar/sacral facet joint radiofrequency
ablation. Our reviewer says that the enrollee does not meet criteria for the requested lumbar/sacral facet joint radiofrequency ablation. Our physician reviewer found the physician chose to break up these sessions into right and then left sided. The request for a fourth session exceeds utilization limits. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar/sacral facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency ablation
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 5, 2021, to August 6, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were only there for one day and the inpatient care was denied. 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 $300 copayment for each inpatient admission.   The file shows that your inpatient stay was approved, and you were in the hospital from August 5, 2021, to August 6, 2021. Therefore, you have been asked to pay a $300 copayment for the inpatient hospital services. Inpatient hospital services fall within the Inpatient Hospital 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 inpatient hospital services provided from August 5, 2021, to August 6, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The Plan denied your request. The Plan says that the requested Retacrit is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Retacrit. Our reviewer says that the requested Retacrit is medically necessary. Our physician reviewer found the requested use of Retacrit is FDA-approved for the enrollee's diagnosis. The enrollee has anemia of chronic kidney disease. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve Retacrit.

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 waive the copayment for tissue excision of the ear performed on October 21, 2021.

You asked the Plan to waive the copayment for the tissue excision. You say that you feel that you should not have to pay the copayment for the second surgery since the provider did not remove all the tissue the first time. 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 $350 copayment for each outpatient surgery in an outpatient hospital facility. 

You have been asked to pay a $350 copayment for the tissue excision. The tissue excision 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 copayment for tissue excision of the ear performed on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure (CPAP) supplies provided on August 23, 2021.  

You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you feel that the supplies should be covered in full since they are needed every so often. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment (DME), including CPAP supplies.     

Item Allowed Amount 20% Coinsurance 
Full Mask, Cushion, Headgear, Filters $247.78 $49.55 
Tubing, Water Chamber $34.47 $6.89 
Total:  $56.44  

You have been asked to pay $56.44, which is 20% of the allowed amount for the CPAP supplies. The CPAP supplies fall within the Durable Medical Equipment (DME) and Related 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 continuous positive airway pressure (CPAP) supplies provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve destruction of the intraosseous basivertebral nerve for the enrollee.  You asked the Plan to pre-approve the services. You say that this is the most appropriate procedure to achieve long term relief. The Plan denied your request. The Plan says this procedure does not meet the definition of medical necessity.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is needed to show safety and efficacy.  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 destruction of the intraosseous basivertebral nerve for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided August 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the tooth extractions. You say that you were not told that the dentist was OON. The Plan denied your request. The Plan says these services are not covered when they are rendered OON.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the tooth extractions they are provided in-network.   We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the tooth extractions have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on September 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for treatment with Prolia (J0897) provided on March 22, 2021, by an out-of-network provider.  

You asked the Plan to pay for Prolia. You say that the enrollee did not advise at the time of service that the enrollee's policy had changed. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  

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. It is the provider's obligation to confirm insurance coverage and authorization requirements prior to rendering services. 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 treatment with Prolia (J0897) provided on March 22, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 7, 2021, to September 11, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were hoping there was extra help for these bills due to your coronavirus diagnosis. 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 $300 per day for days 1-5 and $0 per day for additional days for each inpatient stay. 

The file shows that you were in the hospital from September 7, 2021, to September 11, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $300 per day for the first 4 days for the inpatient hospital services. The total for your stay is $1200 ($300 copayment x 4 days = $1200). The inpatient hospital services fall within the Inpatient Hospital 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 inpatient hospital services provided from September 7, 2021, to September 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2021, through August 15, 2021.  

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of the inpatient hospital admission does not meet the requirements for approval.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2021, through  August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on August 19, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.  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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on August 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for psychotherapy telehealth services provided from September 8, 2021, to September 21, 2021.  

You asked the Plan to waive the deductible for the psychotherapy telehealth services. You say that you did not have any copayments before and you cannot afford these charges. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to certain items and services.   

The psychotherapy telehealth services you asked the Plan to waive the deductible for falls within the Outpatient Mental Health Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Outpatient Mental Health Care. Please note that the cost-share waivers for telehealth visits ended on August 31, 2021. This cost sharing is a contractual obligation that had not been met at the time the psychotherapy telehealth services was received on September 8, 2021, to September 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy telehealth services provided from September 8, 2021, to September 21, 2021.