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

 We decided that the Plan does not have to pay for the intravenous immune globulin (IVIG) treatment provided on July 9, 2021.  

You asked the Plan to pay for the IVIG treatment. You say that the treatment was medically necessary and should be reimbursed. The Plan denied your request. The Plan says the criteria for coverage of IVIG were not met based on the provided records.  

The Plan follows Medicare rules. Medicare rules say that IVIG treatment is considered reasonable and necessary when the criteria in the Medicare rules section 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 pay for the IVIG treatment. Our reviewer says that the documentation does not support that criteria are met for this treatment. Our physician reviewer found the record indicates that the enrollee has IgG Kappa multiple myeloma. The record does not indicate that there has been one documented, serious bacterial infection requiring IV antibiotic therapy in the previous six months or two or more such infections in the previous one year, or that there has been a failure to mount an appropriate IgG humoral response to pneumococcal vaccine. The elements of the coverage rules 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 IVIG treatment have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous immune globulin (IVIG) treatment provided on July 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brovana (aformoterol).  

You asked the Plan to pre-approve the Brovana. You say that it is felt that this drug is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the preferred drug has not been tried as required by step therapy rules.  

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 the Brovana. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the record indicates that the enrollee has emphysema. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative, Perforomist. 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.  

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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (aformoterol).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  You asked the Plan to pre-approve the PET scan. You say that this test is medically necessary. The Plan denied your request. The Plan says this test is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested PET scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee  has dementia related to Parkinson's or Lewy Body disease.  The record indicates that a magnetic resonance imaging (MRI) shows tempero-parietal atrophy. The record does not indicate that the enrollee satisfies the criteria for fronto-temporal dementia  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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services you received from August 26, 2021, to August 31, 2021.  

You asked the Plan to waive the copayment for the outpatient hospital observation services. You say that the hospital didn't let you go home even though your surgery wasn't scheduled for two weeks later. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for outpatient hospital observation services.     

You have been asked to pay a $200 copayment for the outpatient hospital observation services. This copayment applies regardless of the reason for your hospital stay. 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 outpatient hospital observation services you received from August 26, 2021, to August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from April 1, 2021, to April 8, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you believe this copayment should be waived.  You said that you had been in the hospital a few days before this and were sent home.  You said that you developed an infection and had to be readmitted.  You said that because of this, the second stay should be a continuation of the first stay and a new copayment should not apply. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment per day for days 1-5, and $0 for additional days for inpatient hospital care.     

Records show that you were in the hospital for seven days during this admission.  You were charged a $200 copayment per day for each of the first five days, for a total of $1000. The inpatient hospital cost sharing applies each time you are admitted, regardless of the reason for the admission. 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 care you received from April 1, 2021, to April 8, 2021.
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 requested admission to an IRF does not meet criteria.  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 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. The enrollee's care needs can be met at a lower level of care.  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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy services.  You asked the Plan to pre-approve home health physical therapy services. You say that these services are medically necessary. The Plan denied your request. The Plan says the records do not support the need for this service at this time.  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 home health physical therapy services. Our reviewer says that the requested services do not meet criteria for coverage. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The patient is ambulating 420 feet with an assistive device. She has been educated on safety and fall precautions. She does not require ongoing skilled physical therapy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve additional SNF services. You say that you are not ready for discharge and require continued care. The Plan denied your request. The Plan says the you no longer meet requirements for SNF coverage.  

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 additional SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with  the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter  you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the skin graft procedure and the Affinity amniotic membrane you received at a podiatrist's office on June 11, 2021.  You asked the Plan to waive the cost sharing for the skin graft procedure and the Affinity membrane. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing 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 $35 copayment for specialist services and 20% coinsurance for Medicare Part B drugs and biologicals.    You have been asked to pay a $35 copayment for the skin graft procedure and 20% coinsurance for the Affinity membrane. You had the skin graft procedure in a specialist's office.  In addition, the Affinity membrane is a biological that Medicare pays for under the Medicare Part B drug fee schedule. 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 cost sharing for the skin graft procedure and the Affinity amniotic membrane you received at a podiatrist's office on June 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on August 19, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a routine colonoscopy and you have not been billed for them in the past. The Plan denied your request. The Plan says you were charged this copayment 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 $550 copayment for outpatient surgery.     You have been asked to pay a $550 copayment for the diagnostic colonoscopy. We looked at the medical records to determine the type of colonoscopy you had.  This colonoscopy was not ordered as a screening procedure.  Rather, this colonoscopy was performed as part of an evaluation of persistent right lower quadrant abdominal pain. Therefore, this is a diagnostic procedure for which the outpatient surgery copayment applies. 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 diagnostic colonoscopy you had at an outpatient hospital facility on August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cervical endoscopy procedure you had at an outpatient hospital facility on July 23, 2021.  

You asked the Plan to waive the copayment for the cervical endoscopy procedure. You say that you have this procedure every year and have not had to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this procedure ($211.67) is less than your copayment, you are responsible for the full allowed amount.  The Plan also says that it looked at your claim history and confirmed that you also were charged a $211.67 copayment in 2020 for this procedure as well.  

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 outpatient surgery.   

You have been asked to pay a $300 copayment for the cervical endoscopy procedure. The cervical endoscopy procedure falls within the outpatient surgery 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 cervical endoscopy procedure you had at an outpatient hospital facility on July 23, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 23, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you received monoclonal antibodies for COVID-19, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. There were no copayment waivers in effect at the time of these services, even if the services are related to COVID-19.  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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. Your Plan's website explicitly states that for COVID-19 treatment, your cost sharing will be according to your benefit plan.  You are still responsible for any cost sharing for these services. 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 emergency room (ER) visit you had on April 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transportation provided on August 4, 2021.  

You asked the Plan to pay for the ambulance transportation. You say that this was medically necessary transportation, and the diagnosis codes are supported. The Plan denied your request. The Plan says a valid secondary diagnosis code was not reported on this claim as required.  

The Plan must follow Medicare rules. Medicare rules say that for ambulance claims in the State of New Jersey, a secondary diagnosis codes from a list of four must be reported. These codes are Z74.01, Z74.3, Z78.1, or Z99.89.     

In this case, the claim does not include one of the four required secondary diagnosis codes. As such, the local billing rules for Medicare ambulance claims have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 38747) provided to the enrollee on June 15, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is inclusive to another billed code.  

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 38747 is a column II code to column I code 47122. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 38747) provided to the enrollee on June 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided on June 28, 2021.  You asked the Plan to waive the copayment for physical therapy. You say that you already paid the copayment. The Plan denied your request. The Plan says the copayment 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 $35 copayment for Medicare covered physical, occupational and speech therapy visits from an in-network provider.     You have been asked to pay a $35 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Contact the Plan regarding any balance due. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-ray (D0230), pulp vitality test (D0460), crown (D2740 x 3), core build up (D2950 x 3), pontic (D6240), and root canal (D3310) provided on September 11, 2020.  

You asked the Plan to pay for the periapical x-rays, pulp vitality test, crowns, core build up, pontic, and root canal. You say that the dental work was medically necessary. You also say that you were never given a correct address to send the claim. The Plan denied your request. The Plan says that periapical x-rays, crowns, core build up, pontic, and root canal are not listed as covered services.  

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.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-ray (D0230), pulp vitality test (D0460), crown (D2740 x 3), core build up (D2950 x 3), pontic (D6240), and root canal (D3310) provided on September 11, 2020.