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

We decided that the Plan does not have to waive the coinsurance for the office visit (99214) rendered by the out-of-network (OON) provider on June 7, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 50% of the Medicare-allowed amount for an out-of-network specialist visit for Medicare-covered services.
You have been asked to pay $50.58 (Medicare allowed amount of $101.16 x 50% coinsurance) for the office visit rendered by an out-of-network specialist. 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 office visit (99214) rendered by the out-of-network (OON) provider on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 Wheel Walker purchased on June 1, 2021.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this walker. The Plan denied your request. The Plan says this provider is not an eligible Medicare provider for durable medical equipment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided by a physician or practitioner who is not a Medicare eligible provider. The is provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 4 Wheel Walker purchased on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $290 copayment for ambulance transport provided on May 5, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct and you cannot afford it. The Plan denied your request. The Plan says this copayment is a contractual obligation based on the services rendered.
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 $290 copayment for each one-way ambulance transport. 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 $290 copayment for ambulance transport provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for diagnostic two-level medial branch blocks.
You asked the Plan to pre-approve the services. You say that this is is medically necessary. The Plan denied your request. The Plan says neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable.
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 review indicates that there was no documentation provided necessitating the use of anesthesia for the medial branch blocks. 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 anesthesia for diagnostic two-level medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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. Bone marrow aspirate remains experimental for use as bone graft material in spinal surgery. More research is needed to show safety and efficacy. 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 bone marrow aspiration for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic imaging you had on April 22, 2021.
You asked the Plan to waive the copayment for the scanning computerized ophthalmic imaging. You say that you have had these services in the past and they were included in your office visit 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 service ($39.49) is less than your copayment obligation, you are responsible for the full allowed 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 $50 copayment for outpatient diagnostic tests.
You have been asked to pay a $50 copayment for the scanning computerized ophthalmic imaging. The scanning computerized ophthalmic imaging falls within the outpatient diagnostic tests benefit category. This is a separate benefit category from an office visit, so separate cost sharing can apply. 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 scanning computerized ophthalmic imaging you had on April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 

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 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has pain in the right shoulder and muscle strain with 
impingement syndrome. He has had a total of 25 physical therapy visits and instruction in a home exercise 
program. The records do not show that the requested therapy is generally accepted as specific and effective 
therapy for the patient's condition beyond what was approved by the health plan. The records do not show that 
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. 
Additional services are 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 12 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and reline complete maxillary denture (D5730) provided on April 29, 2021, provided by an out of network provider.
You asked the Plan to pay for the dental services. You say that the booklet advises that in network and out of network services are covered the same. You say that when the enrollee's bill was received, the basic costs were not covered. You say that the enrollee expected to pay for the work done on the appliance. You also say that you were led to believe that preventive care would be covered per your benefit. The Plan denied your request. The Plan says dental services are paid based on the maximum allowable charge (MAC).
The Plan says that that if you choose to see an out of network dentist, you may be billed for charges over what the plan pays even for services listed with a $0 copayment. The Plan also says that reline complete maxillary denture is not listed as a covered service.
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 and the services are listed as covered, dental services performed out of network may have a higher cost share amount. The record shows that the Plan paid 100% of the allowed amount for the oral exam, or $19, and prophylaxis, or $ 42. The Evidence of Coverage clearly states that out of network providers may bill you for any amount over what the Plan pays. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, reline complete maxillary denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and reline complete maxillary denture (D5730) provided on April 29, 2021, provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a GeneSight Psychotropic Assay (81291, 81479) provided on April 21, 2021.

You asked the Plan to pay for a GeneSight Psychotropic Assay. You say that this service is not experimental. You also say that it is a pharmacogenomic test that analyzes clinically important variations that may affect a patient's response to psychiatric medications. The Plan denied your request. The Plan says the service requested is considered experimental.

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 pay for GeneSight Psychotropic Assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found several of the tests, are not considered to be clinically efficacious for the enrollee's condition. It does not appear that nongenetic factors have been considered prior to ordering this testing. The GeneSight Psychotropic Assay 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 GeneSight Psychotropic Assay have not been met. Therefore, we decided that the Plan does not have to pay for a GeneSight Psychotropic Assay (81291, 81479) provided on April 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services from an out-of-network provider on November 9, 2020.
You asked the Plan to pay for physical therapy services. You say that the office, individual providers and referring provider are participating providers with Medicare. You say that since the services were medically necessary and should be approved for payment. The Plan denied your request. The Plan says out-of-network services were not authorized. 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. Therefore, we decided that the Plan does not have to pay for physical therapy services from an out-of-network provider on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management provided on May 22, 2021.

You asked the Plan to pay for observation discharge management. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the qualifying initial or subsequent observation care or other service resulting in an observation stay was not found in the enrollee's history; therefore, the 99217 observation care discharge is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

 In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management.
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for observation discharge management. Our reviewer says that code 99217 does not meet the criteria for payment.

Our reviewer found if the emergency room physician is the one who made the decision to admit to observation then they would bill for the admission, not the emergency room charges, but can include the work provided prior to the admission when determining the level of the admit code. In this case, an initial observation code should be reported instead of the emergency room visit code, along with any charges that took place during the emergency room visit prior to observation admission. Therefore, the emergency room visit should be coded as initial observation. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of observation discharge management have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management provided on May 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary for the enrollee. The
Plan denied your request. The Plan says the step therapy requirements have not been met.
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 Procrit. Our reviewer says that Procrit
is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the
enrollee has tried and failed the Plan's preferred drug, zoledronic acid. The reviewer also found that there is no
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the
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 Procrit have not been met. Specifically, the file shows that the enrollee has not
tried and failed the preferred drug. Therefore, we decided that the Plan does not have to pre-approve Procrit
(J0885).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to approve these services. You say that you still have a tremendous need for skilled care. 
The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 12, 2021 and 
October 12, 2021. The Plan has covered 100 days of SNF care. 

Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), 2D oral or facial photographic image (D0350), and cone beam computed tomography (CT) (D0367) provided on June 16, 2021.
You asked the Plan to pay for the dental services. You say that you did not know that these services would not be covered. The Plan denied your request. The Plan says the oral hygiene instruction, photographic image, and cone beam CT 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 oral hygiene instructions (D1330), 2D oral or facial photographic image (D0350), and cone beam computed tomography (CT) (D0367) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (92201) provided April 22, 2021.
You asked the Plan to pay for the extended ophthalmoscopy. You say that you don't understand why this service isn't covered. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that in order for an extended ophthalmoscopy to be covered your medical record must contain documentation that fully supports the medical necessity for extended ophthalmoscopy for each eye, as it is covered by Medicare. We looked at the file, and Medicare rules. In this case the Plan requested medical records for review. The medical records were not received. Therefore, we are unable to determine that Medicare rules for coverage of the extended ophthalmoscopy have been met. Therefore, we decided that the Plan does not have to pay for the ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (92201) provided April 22, 2021.