Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency department services provided on April 17, 2021.  You asked the Plan to waive the copayment for the emergency department services. You say that you would like reconsideration because you have a balance of over $800 and cannot afford this bill. The Plan denied your request. The Plan says the copayment assessed is correct.  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 $120 copayment for Emergency Care.   You have been asked to pay a $120 copayment for the emergency department services. These services fall within the Emergency 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. Please note, the Plan has indicated that the provider has confirmed that you are only responsible for your $120 copayment. Please contact the Plan if you are being billed in excess of your contracted copayment amount. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department services provided on April 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits for the enrollee.  You asked the Plan to pre-approve eight (8) additional physical therapy visits. You say that these services are medically necessary. The Plan denied your request. The Plan says that a home exercise program should help you reach your final goals.  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 eight (8) additional physical therapy visits. 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 that the enrollee's condition does not meet Medicare criteria for eight (8) additional physical therapy visits.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits for the enrollee.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory services provided to the enrollee on April 28, 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 that this testing was not ordered or approved by the ordering provider as per the outreach response.  The Plan must follow Medicare rules. Medicare rules say that services are covered 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the services were medically reasonable and necessary for the enrollee. There was evidence of a valid order by the ordering provider.  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 been met. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on April 28, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that medical evidence clearly supports the use of the Intracept procedure as the primary treatment for chronic low back pain. You say that medical necessity is supported by the clinical and diagnostic patient data. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that current medical literature indicates that the service being requested is considered experimental and investigational. The Plan says that this procedure is not identified as widely used or generally accepted for the proposed use.  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 an Intracept procedure. Our reviewer says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint injection.  You asked the Plan to pre-approve the SI joint injection. You say that you would like reconsideration because the requested SI joint injection is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested SI joint injection.  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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found neither of the prior SI joint injections provided sustained pain relief.  Therefore, repeating them is not indicated.  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 SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) and an unspecified adjunctive procedure (D9999) provided on May 5, 2021.  You asked the Plan to pay for an unspecified preventive procedure and an unspecified adjunctive procedure. You say that you were in a lot of pain on the left side of your ear, eye, and jaw. Your doctor referred you to a specialist. After seeing this specialist, your mouth pain was relieved. The Plan denied your request. The Plan says the services requested are not a covered benefit.  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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) and an unspecified adjunctive procedure (D9999) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (64483) provided on September 16, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 a $550 copayment for outpatient surgery per visit including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $550 copayment for the outpatient surgery provided at an outpatient hospital facility. The service provided in this case is classified as a surgical procedure. 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 injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (64483) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on August 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 the domiciliary or rest home visit (99336) provided on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) (43235) provided September 14, 2021.  You asked the Plan to waive the copayment for the EGD. You say that this procedure was not performed on this day and you don't feel you should have been billed for it. The Plan denied your request. The Plan says based on the medical records provided, this service was initiated and billed correctly even though the procedure was unable to be completed.  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 $100 copayment for care in a certified ambulatory surgical center.  You have been asked to pay a $100 copayment for the EGD. The EGD as billed falls within the Outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) (43235) provided September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the proton beam radiation therapy (PBRT).  You asked the Plan to pre-approve the PBRT. You say that you would like reconsideration because the requested radiation therapy is medically necessary. The Plan denied your request. The Plan says there is no current research showing that the member's type of cancer responds better to the requested type of treatment.  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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at the present time, the clinical superiority of protons compared with photons is not clearly established for breast cancer. Only a single arm study has showed efficacy but has not been directly compared to photons therapy which is the standard 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 the PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve the proton beam radiation therapy (PBRT).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of anesthetic agent coded 64415-59 provided on April 5, 2021.  You asked the Plan to pay for the injection of anesthetic agent. You say that the medical records support payment for this claim. The Plan denied your request. The Plan says the documentation does not support separate payment for the services as billed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 injection of anesthetic agent. Our reviewer says that the documentation does not support the use of the -59 modifier to support separate payment for the services rendered. Our physician reviewer found the anesthesia report documents "ANES START 0905 and ANES END 1013"; "Peripheral Nerve Block start time 0910 and End time 0918".    Per the Centers for Medicare and Medicaid Services (CMS), "If the operating physician requests that the anesthesia practitioner perform pain management services after the postoperative anesthesia care period terminates, the anesthesia practitioner may report it separately using modifier 59 or XU". In this case, peripheral nerve block was given during anesthesia time and the criteria is not met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection of anesthetic agent have not been met. Therefore, we decided that the Plan does not have to pay for the injection of anesthetic agent coded 64415-59 provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 24, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like the Plan to pay 50% for this exam because you do not have the money to pay for it. The Plan denied your request. The Plan says this service is not a covered dental benefit under your plan.  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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy (90837) provided on September 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy. You say that no authorization is required for out of network (OON). The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 psychotherapy (90837) provided on September 15, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar medial branch block (MBB) services.  You asked the Plan to pre-approve lumbar MBB services. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the requested injection services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when medically necessary and when there is an absence of untreated radiculopathy or neurogenic claudication.   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 MBB services.  Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has low back pain with associated radiculopathy. There is the presence of "untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)."  Therefore, the review has determined that the medical records provided do not meet the requirements for coverage.  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 MBB services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch block (MBB) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on June 9, 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 CPT code 99153 has a Professional Component(PC)/Technical Component (TC) indicator of 3 per the April 2021 National Physician Fee Schedule Relative Value File.  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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)."  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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the services were billed with Place of Service 22 On-Campus Outpatient Hospital.   assigned this code a Professional/Technical Component (PCTC) indicator "3" effective for dates of service on or after January 1, 2017. Technical components are not separately payable when performed by a physician in a facility setting because the facility has staff on hand to perform those services."    We looked at this coder'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 pay for moderate sedation services (procedure code 99153) provided to the enrollee on June 9, 2021.