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

We decided that the Plan does not have to waive the coinsurance for the injection provided out-of-network on May 20, 2021.
You asked the Plan to waive the coinsurance for injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260) and injection, dexamethasone sodium phosphate, 1 mg (J1100). You say that you should not be responsible for the doctor failing to get preauthorization. The Plan denied your request. The Plan says the services were out-of-network and the coinsurance was charged 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 30% coinsurance for Outpatient Surgery, out-of-network.
You have been asked to pay 30% coinsurance for injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260) and injection, dexamethasone sodium phosphate, 1 mg (J1100). Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260) and injection, dexamethasone sodium phosphate, 1 mg (J1100) fall within the Outpatient Surgery, out-of-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection provided out-of-network on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) and two abutment supported retainers (D6069 x2) provided on May 4, 2021.
You asked the Plan to pay for the prefabricated abutments and abutment supported retainers. You say that the treating provider is in-network. You also say that if these services had been coded correctly some of the items could be covered. The Plan denied your request. The Plan says these services are not covered.
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. The record shows that you signed a pay agreement with the provider, prior to the services being rendered, acknowledging that you would be responsible for paying the full amount if your claim was denied. Therefore, we decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) and two abutment supported retainers (D6069 x2) provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 7, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you say that you did not call the ambulance, but your neighbor did. You also say that your blood pressure was checked, and you never rode in the ambulance. The Plan denied your request. The Plan says the zip code in which you were transported from is not considered a rural location.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 7, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. In addition, you do not have documented skilled therapy needs. You are consistently ambulating more
than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy provided from April 13, 2021, to April 14, 2021.
You asked the Plan to waive the copayment for the physical therapy visit. You say that this charge is not correct because it should be included in your $295 copayment for the surgery. The Plan denied your request. The Plan says you have been asked to pay 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 $25 copayment for each in-network Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $25 copayment for the physical therapy visit. The physical therapy visit 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. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy provided from April 13, 2021, to April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided January 14, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you do not believe you should be charged for this follow-up service. The Plan denied your request. The Plan says the copayment has processed 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 $45 copayment for specialist physician services. You have been asked to pay a $45 copayment for the office visit. This service falls within the specialist physician 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 office visit (99213) provided January 14, 2021.
Your complaint about your provider coding this as a standalone office visit 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and related accessory
provided on March 23, 2021.
You asked the Plan to pay for the services provided. You say that the device allows the enrollee to ambulate
freely at home. The Plan denied your request. The Plan says the service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that a pneumatic compression device (E0675) and segmental gradient pressure pneumatic
appliance (E0673) were provided for the treatment of chronic pain. We looked at the file, and Medicare rules.
There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied
as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the
pneumatic compression device and related accessory provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee arthroscopy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that 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 services are not medically necessary. Our physician reviewer found the enrollee is being treated for other meniscus derangement of the right knee. She presented with persistent right knee pain with noted Baker's cyst. She was minimally improved with the aspiration due to difficulty within the Baker's cyst. Her symptoms remain unchanged. There is effusion and positive for posterior mass, which is consistent with a Baker's cyst. There is no compelling rationale or extenuating circumstances to support that the knee arthroscopy is reasonable or medically necessary at this time.

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 a knee arthroscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically
ill or critically injured patient; first 30-74 minutes (99291) provided March 4, 2021.
You asked the Plan to pay for the critical care, first 30-74 minutes. You say that the code is payable as coded
and billed. The Plan denied your request. The Plan says the documentation submitted did not support a critical
care visit of 30-74 minutes was performed on the billed date of service
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
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 critical care. Our reviewer says that the records do not
support the billing of critical care, evaluation and management of the critically ill or critically injured patient;
first 30-74 minutes (99291) for date of service March 4, 2021. Our reviewer found that the documentation
submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The
documentation did not include the time spent providing this service; therefore, the billed Critical Care
Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact
the provider for additional information. The review indicates that the medical record did not support the billing
of 99291 for date of service March 4, 2021.
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 critical care, first 30-74 minutes have not been met. Therefore, we decided
that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or
critically injured patient; first 30-74 minutes (99291) provided March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa cap 1mg tablets for the enrollee.
You asked the Plan to pre-approve the tablets. You say that this is medically necessary. The Plan denied your
request. The Plan says this does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa cap 1mg tablets for
the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the injection services provided on July 10,
2020, and July 24, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that this medication has always
been covered under Part D. The Plan denied your request. The Plan says your obligation to the services was
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 20% of
the total cost for Medicare Part B prescription drugs.
The file shows that you received a Methylprednisolone and Rituximab injection on each date of service. You have been asked to pay 20% of the total cost for the services provided. The services fall within the Medicare Part B prescription drugs 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 cost shares for the injection services provided on July 10, 2020, and July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970) provided on March 17, 2021.

You asked the Plan to pay for the extremity study. You say that there is no Local Coverage Determination (LCD) or National Coverage Determination (NCD) guidelines that say this service is not payable with the diagnosis on the claim, R50.9. The Plan denied your request. The Plan says according to the Medicare LCA, procedure code 93970 is not covered for the enrollee's diagnosis code, R50.9. The Plan says that since R50.9 is not listed, it does not support medical necessity. The Plan also says that it is not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure code 93970 is medically necessary when performed as a result of specific ICD-10-CM codes.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Specifically, the record shows that the enrollee's diagnosis, R50.9, is not listed as a covered diagnosis code. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970) provided on March 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a HHA (S9122).
You asked the Plan to pre-approve the HHA. You say that you live alone and would benefit drastically from someone taking care of and assisting you post-surgery. The Plan denied your request. The Plan says you do not meet the criteria for coverage for HHA services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the HHA. Our reviewer says that the HHA services are not medically reasonable and necessary. Our physician reviewer found the records do not document that you are receiving or in need of any skilled nursing services or skilled therapy services and the records do not clearly document that you are confined to the home.
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 HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a HHA (S9122).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.

You asked the Plan to pre-approve home health skilled nursing services. You say that you continue to require home health skilled nursing services. The Plan denied your request. The Plan says the criteria for home health services have not been met.

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 skilled nursing services. Our reviewer says that the requested home health is not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. He had diagnostic genicular nerve blocks. The right side block gave 50 percent pain relief on the right and 100 percent on the left. Genicular RFA is considered experimental in nature and is the subject of ongoing clinical trials. The services are therefore 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 genicular nerve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an Ultra lightweight wheelchair (K0005) provided to the enrollee on April 26, 2021.

You asked the Plan to pay this claim. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for this wheelchair.

Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that prior authorization is required for durable medical equipment. The Plan did not pre-approve this wheelchair. Therefore, we decided that the Plan does not have to pay for an Ultra lightweight wheelchair (K0005) provided to the enrollee on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network office consultations.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be redirected to an in-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for out-of-network office consultations.