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

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breasts.  You asked the Plan to pre-approve the MRI. You say that the Food and Drug Administration recommends periodic imaging for silicone breast implants. You feel that this means it must be considered medically necessary. The Plan denied your request. The Plan says this imaging is not medically necessary without any clinical indication of rupture. There are also alternative imaging modalities that should be used before MRI.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a history of breast cancer and Allergan implants.  The record does not indicate the presence of any symptoms.  The record indicates that the enrollee has not undergone any type of imaging. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breasts.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pre-approve the requested LDCT scan. You say that the current guidelines recommend this screening after 50 years of age with a 20 pack-year history or more. The Plan denied your request. The Plan says the Medicare criteria for coverage of the LDCT requires an age of more than 55 and a 30 pack-year history.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.    We reviewed the file and the Medicare rules. We find that the enrollee is not between 55 and 77 years of age and does not have a smoking history of over 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that it is not safe to go home at this time. You say that, to achieve the next level of care and get 75% level in the activities of daily living, you need a few more weeks in a SNF. The Plan denied your request. The Plan says the enrollee is now at a level where she can transition from daily skilled services to services that are provided intermittently.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services but not on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the elbow orthosis you received on January 20, 2021.  You asked the Plan to waive the coinsurance for the elbow orthosis. You say that this item was supposed to help you post-surgery, but it didn't do anything.  You state that you have seen similar items online for $9 and you were never told what the cost of this device would be.  You stated that had you known the cost, you would never have taken it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prosthetic devices and related supplies.   You have been asked to pay 20% coinsurance for the elbow orthosis. The elbow orthosis falls within the prosthetic devices and related supplies benefit category. This cost sharing applies regardless of how much this item may cost online or how helpful the item was to you. 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 elbow orthosis you received on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ostomy supplies you received from January 12, 2021, to January 20, 2021.  You asked the Plan to waive the copayments for the ostomy supplies. You say that you order supplies monthly, but the supplier mailed them to you in three separate mailings.  You stated that as a result, you were charged three different copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $20 copayment each for prosthetic supplies.   You have been asked to pay a $20 copayment each for the ostomy supplies. The ostomy supplies fall within the prosthetic 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 copayments for ostomy supplies you received from January 12, 2021, to January 20, 2021.   Your complaint about how this supplier packages and ships these items is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the health problem.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ablation bone tumor radiofrequency percutaneous, including computed tomographic guidance.  You asked the Plan to pre-approve ablation bone tumor radiofrequency percutaneous services. You say that the enrollee has already been approved for the vertebral augmentation procedure L1 and both services must be performed at the same time out of medical necessity. The Plan denied your request. The Plan says the service in dispute 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 ablation bone tumor radiofrequency pepercutaneouservices. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a fracture, but there is no evidence of facet joint pain on physical examination.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ablation bone tumor radiofrequency percutaneous services have not been met. Therefore, we decided that the Plan does not have to pre-approve ablation bone tumor radiofrequency percutaneous, including computed tomographic guidance.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the dermatology services provided on August 23, 2021.  You asked the Plan to pay for the dermatology services. You say that you were referred to this provider by a network provider that practices in the same office. The Plan denied your request. The Plan says that the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the dermatology services by a contract provider. The file does not show that the Plan provided notice that the dermatology services would not be covered. Under Medicare rules, this means the dermatology services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the dermatology services provided on August 23, 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 pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 5, 2021 to June 29, 2021.  You asked the Plan to pay for codes J0604-AX and 90999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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 J0604 is Cinacalcet, oral, 1 mg, (for esrd on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.  We find that CPT codes J0604-AX and 90999 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of codes J0604-AX and 90999 have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 5, 2021 to June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the out of area office visits and laboratory services provided from July 7, 2021, to July 16, 2021.  You asked the Plan to pay for the out of area office visits and laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent for coverage of out of area care.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.     We looked at the file and Medicare rules. The file shows that the office visit and laboratory services provided to you were not due to an unforeseen illness or condition and there were no attempts made to get the services approved by the Plan. Based on this information, we decided that Medicare rules for coverage of the out of area office visits and laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the out of area office visits and laboratory services provided from July 7, 2021, to July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from May 4, 2021, to May 11, 2021.  You asked the Plan to waive the copayment for inpatient hospital services. You say that you were advised by the Plan that you would not have any financial responsibility on the claim. The Plan denied your request. The Plan says you were 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 $305 copayment per day for Inpatient Hospital Services for days 1-7.   You have been asked to pay a $305 copayment per day for seven days for inpatient hospital services, which is a total of $2,135 ($305 x 7 = $2,135). 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 rendered from May 4, 2021, to May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided the Plan does not have to pay for radiology services provided to the enrollee on August 27, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request.  The Plan says the enrollee did not have prior authorization and the records provided do not support the services billed. The enrollee also on the same date of service also had a CT angiography and CT scan of the head, procedure code with contrast, procedure code 70496, that was submitted by the non-participating provider and paid by the health plan. Mutually exclusive edits consist of combinations of procedures that differ in technique  or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. Procedures 70450 and 70496 include imaging of the head or brain. Procedure 70496 however, is a more comprehensive procedure that includes imaging procedures 70450 as well as additional components. Additionally, CPT 2008 verbiage for procedure 70496 states "including non-contrast images." Therefore, this claim cannot be paid as billed.   Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules also state providers must submit claims appropriately. 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 Plan appears to have reviewed the case for medical necessity and found the claim submitted cannot be paid as billed as there is a more appropriate CPT that should be used for Medicare claims. We also do not find the enrollee had prior authorization for out of network services. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) and contrast agent provided on June 23, 2021.  You asked the Plan to waive the copayment for an MRI and contrast agent. You say that you were advised that your insurance would cover 100% of the charges. You say that you cannot afford the bill. 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 $160 copayment for in-network radiological diagnostic services, including MRI's. The contract also says that you must pay 20% coinsurance for each medical supply, such as a contrast agent.  You have been asked to pay a $160 copayment for an MRI. You have also been asked to pay $4.23, which is 20% of the allowed amount for medical supplies ($21.15 allowed amount x 20% coinsurance = $4.23). The total for your visit is $164.23. The MRI and supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) and contrast agent provided on June 23, 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 based on the documentation provided you only requires short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bronchial thermoplasty treatment.  You asked the Plan to pre-approve the bronchial thermoplasty. You say that this treatment is necessary for the enrollee's condition. The Plan denied your request. The Plan says peer-reviewed literature considers bronchial thermoplasty experimental and investigational for the treatment of asthma and other indications (such as chronic obstructive pulmonary disease) because its effectiveness has not been established.  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 bronchial thermoplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 70-year-old man with a diagnosis of Severe persistent asthma, uncomplicated. It is documented that his symptoms have been poorly controlled for the last few decades. The enrollee has been treated numerous times for bronchitis and asthma exacerbation with steroids and antibiotics. The most recent pulmonary function tests showed evidence of mild obstruction with a significant bronchodilator response and mild gas transfer defect.  It is not clear that bronchial thermoplasty is medically reasonable and necessary for the enrollee in this case. The 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program regarding the management of asthma in adolescents and adults states, "bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort."  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 bronchial thermoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty treatment.