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

We decided that the Plan does not have to pre-approve the removal of a cataract from the right eye.

You asked the Plan to pre-approve the cataract removal. You say that you would like reconsideration because surgical repair in the left eye followed by the right consecutively is medically necessary due to high level of myopia. The Plan denied your request. The Plan says the member does not meet coverage criteria for cataract removal of the right eye.

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 cataract removal. Our reviewer says that the elements of the coverage criteria have not been satisfied. Our physician reviewer found the record does not document a condition, as enumerated in the coverage criteria, for performing bilateral cataract surgery. 

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 cataract removal have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of a cataract from the right eye.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
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 Durolane is covered when specific criteria are met. 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 pain. There is no documentation of a response to conservative treatment and any other x-ray findings of osteoarthritis, as the notations only document knee effusions. The criteria for coverage are not met and the Durolane is 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 Durolane.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from May 11, 2021, through May 15, 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 services 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 $300 copayment per day for days 1-5 and a $0 copayment per day for additional days for in-network Medicare-covered inpatient hospital care.

You have been asked to pay $1,200 ($300 copayment x 4 days) for the inpatient hospital provided. 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 inpatient hospital care provided from May 11, 2021, through May 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (75571) provided on May 4, 2021.

You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.

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 75571 has a bundled relationship with code 71250 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography scan (75571) provided on May 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have involuntary neck muscle spasms (cervical dystonia) and neck tremors. You have not tried and failed the Plan's required drugs, Dysport or Xeomin. The records do not support that the required drug would be less effective or have adverse effects. Botox is 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 Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided January 2, 2021.

You asked the Plan to pay for the vision services. You say that you do not believe you should return the over payment as services were rendered. The Plan denied your request. The Plan says this claim has been processed as an over payment because no services were rendered.

The Plan must follow Medicare rules. Medicare rules say that the supplier or provider must provide documentation that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, no medical records were provided to indicate that medical services were performed on the date in question. Based on this information, we decided that Medicare rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for out-of-network orthopedic services.

You asked the Plan to pre-approve an in-network exception. You say that you did not realize the doctor was out-of-network for your plan. The Plan denied your request. The Plan says there are in-network providers that can treat your condition.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare. 

The requested provider in this case is not a network provider with the Plan. You have out-of-network benefits. The Plan also has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve an in-network exception. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for out-of-network orthopedic services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 1 additional skilled nursing visit in the home.
You asked the Plan to pre-approve home health services. You say that the additional visit is necessary for recertification and a catheter flush. The Plan denied your request. The Plan says that the documentation does not support the need of additional visits.
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 services. Our reviewer says that the additional skilled nursing visit is medically necessary. Our physician reviewer found Based on the documentation provided, it is my opinion that the health plan's denial should be overturned. The reviewer found that the enrollee was approved for 9 home nursing visits in a 9-week period. The reviewer found that during this period, the enrollee required an emergency nursing visit due to a catheter malfunction. The provider has requested coverage for 1 extra visit, which appears to allow for the emergency visit while still covering the already approved nine weekly visits. Therefore, the reviewer found that the requested service is medically necessary and reasonable.
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 services have been met. Specifically, the file shows that the 1 additional visit was used as an emergency visit. Therefore, we decided that the Plan has to pre-approve 1 additional skilled nursing visit in the home.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided with a total hip arthroplasty (27130) and a halo cast (29000).
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says they have agreed to approve the total hip arthroplasty (27130) and the halo cast (29000); however, the requested inpatient admission and services to be provided with these procedures is not medically necessary. These services are currently approved as an ambulatory procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the provided records do not clearly show evidence to suggest the enrollee would require hospital services after the procedure that would likely cross two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided with a total hip arthroplasty (27130) and a halo cast (29000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 8, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges. 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 $225 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay a $225 copayment for inpatient hospital care. The services at issue fall within the inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 8, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on April 19, 2021.

You asked the Plan to pay for air ambulance services. You say that you had to be transported via air ambulance
due to a medical condition. The Plan denied your request. The Plan says the request does not meet the
Medicare or Plan coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON oncology visits. You say that you have been seeing this provider and would like to continue. The Plan denied your request. The Plan says this service is available in-network.
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 oncology visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI).

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 you have chronic neck pain. You have tried transcutaneous electrical nerve stimulation (TENS) therapy and physical therapy. The neurological exam does not indicate disease of the nerve root (radiculopathy) of the neck region. 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 a cervical epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on September 25, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnosis of hypertension and no reported symptoms or family history of inherited cardiac syndromes noted, despite the post-testing finding of a genetic variant associated with left ventricular non-compaction. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in rare known familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing would not currently be recommended for general risk stratification for a patient with a diagnosis of hypertension and would not be considered medically reasonable or necessary in this clinical situation.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on September 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport bus (A0110) provided December 9, 2020.
You asked the Plan to pay for the non-emergency transport bus. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the non-emergency transport bus have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency transport bus (A0110) provided December 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion of a cardiac rhythm monitor for the enrollee.
You asked the Plan to pre-approve the services. You say that this is an important part of patient health monitoring. The Plan denied your request. The Plan says that there is no clinical information documenting medical necessity.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has infrequent atrial arrhythmias, but his symptoms are increasing of late and based on the burden of these, he may require flutter ablation. The infrequency of the rhythm disturbances makes it less likely that an external monitor of limited duration will be adequate to assess the frequency of these rhythm disturbances. As such, replacement of the current end of service implantable Linq monitor for continued longer term monitoring is medically reasonable. Indeed, if ablation is necessary, follow-up with the implantable Linq monitor to assess the efficacy of the ablation procedure would be reasonable and medically necessary as well. The replacement of the implantable Linq monitor therefore meets the CMS medical reasonableness and necessity criteria of the applicable Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). 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 pre-approve insertion of a cardiac rhythm monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided to the enrollee on July 15, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798 remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 15, 2020 and received by the lab on July 16, 2020. Of note, the enrollee resides in Florida and the billing laboratory is located in Georgia; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided to the enrollee on July 15, 2020.