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

 We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (45385) provided September 27, 2021.  You asked the Plan to waive the copayment for the colonoscopy with removal of polyps. You say that this was a preventative screening that should not have a copayment. The Plan denied your request. The Plan says the copayment 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 a $175 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $175 copayment for the colonoscopy with removal of polyps. In this case the colonoscopy was performed due to a medical history of colon cancer and colonic polyps and is therefore considered a diagnostic rather than a screening colonoscopy. The colonoscopy with removal of polyps falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (45385) provided September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Yervoy.  You asked the Plan to pre-approve Yervoy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Yervoy. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic non-small cell lung cancer (adenocarcinoma) with estimated glomerular filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor abberrations. The documentation does not support that the requested use of Yervoy is Food and Drug Administration-approved for the enrollee's diagnosis of metastatic non-small cell lung cancer (adenocarcinoma) with EGFR or ALK genomic tumor abberrations. The use of Yervoy for metastatic non-small cell lung cancer (adenocarcinoma) with EGFR or ALK genomic tumor abberrations is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for outpatient knee surgery you had at an outpatient hospital facility from October 20, 2021, to October 21, 2021.  You asked the Plan to reduce the cost sharing for the outpatient surgery. You say that you had this procedure previously without such high cost sharing. 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 outpatient surgery.   You have been asked to pay 20% coinsurance for the outpatient surgery. This cost sharing applies regardless of what you may have paid for a similar procedure in the past. 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 reduce the cost sharing for outpatient knee surgery you had at an outpatient hospital facility from October 20, 2021, to October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 15 days of residential treatment between November 22, 2021, and December 6, 2021.  You asked the Plan to pre-approve residential treatment. You say that the treatment is medically necessary to help manage the enrollee's alcoholism and mental health conditions. The Plan denied your request. The Plan says that the Plan only cover mental health services if a hospital stay is required. A hospital stay is not required for this situation.  The Plan must follow Medicare rules. Medicare rules say that when it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available.   The contract with the Plan says that the Plan covers mental health care, including care in a  partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it.  We looked at the file, the Medicare rules and the Plan's rules. Based on this information, we decided that Medicare rules for coverage of residential treatment have not been met. Medicare rules say that when it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. The Plan says an inpatient hospital stay is not required for the enrollee's situation. Therefore, we decided that the Plan does not have to pre-approve 15 days of residential treatment between November 22, 2021, and December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Multaq.  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 self-administered drugs are not covered.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Multaq.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that your father has Parkinson's and is unable to walk. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapy services provided from January 12, 2021, to October 13, 2021.
You asked the Plan to waive the copayments for the psychotherapy services. You say that the provider billed everything at once instead of collecting the copayments at the time of service. The Plan denied your request. The Plan says the enrollee has 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for each visit for outpatient mental health services.

Service
Copayment per EOC
Actual Charges
Psych Eval - January 12, 2021
$20
$20
Interactive Complexity - January 16, 2021
$20
$16.15
Interactive Complexity - January 27, 2021
$20
$16.15
Interactive Complexity - February 10, 2021
$20
$16.15
Psychotherapy - February 24, 2021
$20
$20
Interactive Complexity - March 10, 2021
$20
$16.15
Psychotherapy - March 31, 2021
$20
$20
Interactive Complexity - April 14, 2021
$20
$16.15
Psychotherapy - April 28, 2021
$20
$20
Psychotherapy - May 12, 2021
$20
$20
Psychotherapy - May 26, 2021
$20
$20
Psychotherapy - June 9, 2021
$20
$20
Psychotherapy - June 23, 2021
$20
$20
Psychotherapy - July 7, 2021
$20
$20
Psychotherapy - July 21, 2021
$20
$20
Psychotherapy - August 4, 2021
$20
$20
Psychotherapy - August 18, 2021
$20
$20
Psychotherapy - September 1, 2021
$20
$20
Psychotherapy - September 15, 2021
$20
$20
Psychotherapy - September 29, 2021
$20
$20
Psychotherapy - October 13, 2021
$20
$20
Total:
$ 400.75
The enrollee has been asked to pay $400.75 for the psychotherapy services. The psychotherapy services fall within the Outpatient Mental Health Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for psychotherapy services provided from January 12, 2021, to October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.  You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 81001, 85025) rendered by the out-of-network (OON) provider on July 19, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (36415, 80053, 81001, 85025) rendered by the out-of-network (OON) provider on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zilretta.  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 a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has severe bilateral knee primary osteoarthritis. She previously received Zilretta injections on December 23, 2020; July 29, 2021; and November 8, 2021. The Food and Drug Administration (FDA)-approved label for Zilretta states that the safety and efficacy of repeat administration of Zilretta has not been demonstrated. While the label does not preclude repeat administration of Zilretta, the documentation in this case is insufficient to support that repeat dosing of Zilretta is medically reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427), provided on December 19, 2020.
You asked the Plan to waive the copayment for the ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 a $300 copayment for ambulance service. You have been asked to pay a $300 copayment for the ambulance service. This service falls within the ambulance service 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 ambulance service (A0427), provided on December 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 27, 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 an appropriate modifier was not 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your clinical condition does not meet the criteria for acute inpatient rehabilitation.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.     We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot insert (L3332), provided on July 21, 2021.
You asked the Plan to pay for foot orthotics. You say that you need this item. The Plan denied your request. The Plan says this is not a covered item.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot insert (L3332), provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the occupational therapy evaluation (97167) provided on March 23, 2021.  You asked the Plan to pay for the occupational therapy evaluation. 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 therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements.  We find that CPT code 97167 is not supported in the record. Specifically, the record shows that this claim was billed by a nurse practitioner and the services were rendered by an occupational therapist. A nurse practitioner cannot bill for the services of an Occupational Therapist. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation (97167) provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for excision of lesion of spermatic cord (55520-XU-LT) provided on September 8, 2021.
You asked the Plan to pay for excision of lesion. You say that this code can be billed with modifier -XU and the records support this billing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 55520 is inclusive to 49650 and the record does not support the use of the -XU modifier.
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 55520 is excision of lesion of spermatic cord (separate procedure).
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 excision of lesion. Our reviewer says that this code does not meet criteria for payment. Our reviewer found code 55520 has a bundled relationship with code 49560; however, the use of an approved modifier is allowed to unbundle the services provided the records validate the use of the modifier. In this case, the records do not include sufficient documentation to validate the use of -XU to indicate a distinct/separate procedure; therefore, the use of modifier -XU is not appropriate and there is no separate reimbursement for 55520-XU-LT. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision of lesion have not been met. Therefore, we decided that the Plan does not have to pay for excision of lesion of spermatic cord (55520-XU-LT) provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF is the best option for you to be rehabilitated. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation.
Your care needs can be met at a lower level of care such as skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance ride provided by an in-network provider on June 12, 2021.  You asked the Plan to waive the copayment for the ambulance ride. You say that you are appealing the ambulance copayment. 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 $250 copayment for each one-way Medicare-covered ground trip.   You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided by an in-network provider on June 12, 2021.