Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1851x2) and suspension sleeves (L2397x2) provided January 9, 2020.You asked the Plan to pay forthe orthoses. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says limited medical information was provided. The records only records provided was the order form. No clinical documentation was provided. Multiple requests were made for additional records, but no additional records were received. The records provided show there was no face to face encounter documented to substantiate the need for these items. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1851x2) and suspension sleeves (L2397x2) provided January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on February 21, 2020.
You asked the Plan to waive the coinsurance for an office visit. You say that you disagree with the charges because you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit on February 21, 2020 with an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network charges. The allowed amount is $106.40 and 20% of that is $53.20. You have been asked to pay the total coinsurance amount of $53.20 for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on February 21, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to rpre-approvepercutaneous lysis of adhesions (Racz procedure).You asked the Plan to pre-approveRacz procedure. You say that you are appealing with supporting records.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this procedure is considered to be investigational and is not medically necessary.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 o 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 Racz procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has already exhausted conservative treatments, surgery, epidural injection, pain medications, and transcutaneous electrical nerve stimulator (TENS) with limited results. Three systematic reviews and four randomized controlled trials suggested evidence to support the effectiveness of percutaneous adhesiolysis in post-lumbar surgery syndrome, showing significant pain relief for enrollees supporting this procedure.The enrollee in this case appears to have failed all other reasonable and more conservative options, justifying its use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Racz procedure have been met.Therefore, we decided that the Plan has to pre-approvepercutaneous lysis of adhesions (Racz procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an anesthesia injection (64445) provided on June 4, 2019.
You asked the Plan to pay for the anesthesia injection. You say that you would like reconsideration because the records show the procedure was done on the left great toe. The Plan denied your request. The Plan says this service was reported without the required anatomical modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 64445 is not supported in the record. Specifically, the use of an anatomical modifiers is required whenever appropriate. The record indicates that this procedure was rendered on the left great toe, therefore an anatomical modifier is required. Based on this information, we decided that Medicare rules for coverage of the anesthesia injection have not been met. Therefore, we decided that the Plan does not have to pay for an anesthesia injection (64445) provided on June 4, 2019.
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 services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 the enrollee does not require services at the LTACH that are not available at the acute
care hospital where they are currently receiving care. All medically necessary care is being provided in the
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The health plan has approved ongoing care
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp (Darbepoetin J0881).You asked the Plan to pre-approvethe Aranesp. The Plan denied your request. The Plan says based on the enrollee's medical records, a trial of Retacrit is reasonable prior to coverage of Aranesp.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 the Aranesp. Our reviewer says that Aranesp does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee is noted to have anemia. A request has been made for Aranesp to treat the anemia. Our reviewer found that the Plan requires that Retacrit be used. There is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. Our physician reviewer also found that there is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Therefore, the requested Aranesp is not shown to be currently 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 the Aranesp have not been met.Therefore, we decided that the Plan doesnot have to pre-approveAranesp (Darbepoetin J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99327) provided on October 15, 2019 by an out of network (OON) provider. You asked the Plan to pay for an OON domiciliary or rest home visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99327) provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care from February 25, 2020 through February 29, 2020 provided by an out-of-network provider.
You asked the Plan to waive the coinsurance for the services. You say that you are appealing the responsibility due because you would like to disenroll from your plan to join another plan that offers more of your in-network providers. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from February 25, 2020 through February 29, 2020 provided by an out-of-network provider. Your EOC states, enrollees must pay 50% coinsurance per out-of-network admission, 50% coinsurance for out-of-network physician services while inpatient at a hospital. Therefore, you are asked to pay 50% coinsurance for out-of-network services. 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 inpatient hospital care from February 25, 2020 through February 29, 2020 provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral appliance for obstructive sleep apnea (OSA)
provided on January 23, 2020.
You asked the Plan to pay for the oral appliance. You say that this was denied stating that a dentist cannot
provide DME but this item can only be billed by a dentist. The Plan denied your request. The Plan says the
dentist in this case is not a DME supplier and cannot be paid under Medicare for this item.
The Plan must follow Medicare rules. Medicare rules say that oral appliances of OSA are covered as DME. In
order for a supplier to be reimbursed for DME, this supplier must enroll in Medicare as a DME supplier.
In this case, the NPI reported with this claim is for a dentist. This NPI does not indicate that the provider is also
a DME supplier which is required for Medicare payment to be made for this item. Therefore, we decided that
the Plan does not have to pay for the oral appliance for obstructive sleep apnea (OSA) provided on January 23,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on January 28,
2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not payable.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77062. This code
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not
have to pay for the digital breast tomosynthesis rendered on January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on January 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records do not support that there were two separate interpretations of the CT scan. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on January 27, 2020.
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 care is necessary for you to be able to recover properly from your injury. The Plan denied your request. The Plan says your medical condition is stable and you do not require frequent physician supervision of your rehabilitation or an intensive therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee is a 78 year old female with a past medical history of hypertension, multiple sclerosis, degenerative joint disease and spinal stenosis who presented to the acute hospital on 07/25/2020 with a fall resulting in a right femur periprosthetic fracture. She was transferred to another hospital on 07/26/2020 for a higher level of care where she underwent surgical repair of the fracture. She is toe-touch weight bearing with the right lower extremity and is working with physical and occupational therapy. She is not walking presently due to difficulty standing and is minimum to moderate assist for transfers and moderate to maximum assist for activities of daily living. She is medically stable. Transfer to an acute inpatient rehabilitation facility is requested. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364)
provided on February 10, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this CT capture was
ordered to evaluate and provide treatment for a re-root canal where an x-ray did not capture the complete view
of the affected roots. The Plan denied your request. The Plan says this service is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone
beam CT capture and interpretation (D0364) provided on February 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital
on July 14, 2020 with acute kidney injury and stage IV chronic kidney disease. He was treated with antibiotics
for a urinary tract infection. He has no skilled nursing needs. He does not require skilled nursing or skilled
therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forrest home services provided onFebruary 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forrest home services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says these services were not referred by a network provider or rendered in a participating facility. The Plan says that prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providersavailable who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does nothave to pay forrest home services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on February
28, 2020.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that the coinsurance for the
injection is too much and you do not agree with this amount. 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 10%
coinsurance for Part B drugs that are administered by a provider.
You have been asked to pay $134.16 which is 10% of the allowed amount for the Prolia injection. The allowed
amount is $1,341.61. ($1,341.61 x 10% = $134.16). The Prolia injection falls 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 coinsurance for the Prolia injection
provided on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 31, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on December 31, 2019. The allowed amount is $442.20 and 20% of that is $88.44. You have been asked to pay the total coinsurance amount of $88.44 for a Medicare Part B drug. A Medicare Part B drug falls 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 coinsurance for a Medicare Part B drug provided on December 31, 2019.