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

We decided that the Plan does not have to pay for physician services (99239) provided September 15, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 99239 is hospital discharge day management, 31 minutes or more.

We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not document how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc and Synvisc.
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 Euflexxa. Our reviewer says that the request for Euflexxa does not meet criteria. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The reviewer found that the provided documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, the reviewer found that the request for Euflexxa is not approved as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the record shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 26, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until January 30, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided on December 24, 2020.

You asked the Plan to waive the copayment for the wound care. You say that no debridement services were provided. You say you should only be responsible for a $45 specialist 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 $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $370 copayment for the wound care provided at an outpatient hospital.

You have been asked to pay a $362.82 copayment for the wound care. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The medical records show you were seen for a follow-up of a non-healing right leg venous ulcer and an excisional debridement of the ulcer was performed.

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 wound care provided on December 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural injections.
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484). You say that the
enrollee needs the injections for low back pain relief. The Plan denied your request. The Plan says records did not the document pain that is severe enough to cause some degree of functional limitation.
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 injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the documentation did not demonstrate that the enrollee's pain is severe enough to cause some degree of functional limitation. In addition, there is no documentation of a failure of 4 weeks of conservative care. The review has determined that the epidural injections are not medically reasonable or 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 injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484) have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture (D5212) provided on January 29, 2021.
You asked the Plan to pay more for the mandibular partial denture. You say that you were told that this service was covered at 100%. The Plan denied your request. The Plan says $203.50 towards the cost of your partial dentures was correctly paid by the Plan, and you are responsible for the other $253.50. The Plan also says that the dental office confirmed on June 28, 2021 that you paid $150.00 towards the $253.50 balance and $103.50 remains.
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, you are responsible for a $50 deductible plus a 50% coinsurance for the mandibular partial denture. The record shows that you were told prior to receiving this service that you would pay a 50% coinsurance towards the cost of dentures after your
$50.00 deductible is met. There was no misinformation provided. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture (D5212) provided on January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are ready to move out of the hospital you are currently in. The Plan denied your request. The Plan says you do not require an intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that you were admitted to the acute care hospital for left lower quadrant pain, urinary tract infection and pneumonia. Your medical problems are stable. There are no complex nursing needs. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab test (87641) you received on September 23, 2020.
You asked the Plan to pay for the testing. You say that this is a necessary test. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT code 87641 is a test used for screening purposes for which payment will not be allowed. We looked at the file and Medicare rules. The requested lab service is considered to be a screening test, which is not covered by Medicare or your plan. 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 lab test (87641) you received on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic surgery to be provided by an out-of-network provider.
You asked the Plan to pre-approve thoracic surgery. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve thoracic surgery to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 9, 2021, to March 28, 2021.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have skilled nursing needs required or performed during the dates in question.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, the file does not show that the enrollee required daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 9, 2021, to March 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care (99223, 99232) provided from January 25, 2020, through January 26, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the claim was submitted on January 6, 2021. The Plan denied your request. The Plan says the claim was received on February 17, 2021 and the time limit for filing had expired.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for inpatient hospital care was not filed until February 17, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care (99223, 99232) provided from January 25, 2020, through January 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Cosela.

You asked the Plan to pre-approve Cosela. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee is enrolled in a clinical trial and therefore this would be a routine cost that should be covered by Original Medicare.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve Cosela as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve use of Cosela.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve unilateral (right) greater saphenous vein ablation and bilateral stab avulsions for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the medical information did not show the enrollee has met the criteria for coverage because the documentation requires notes that show the procedure called endovenous ablation therapy is limited to patients with absence of vein tortuosity, which would impair catheter advancement.
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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. There is no plan to ablate the left greater saphenous vein due to peripheral artery disease. However, as the patient has a history of varicose bleeds, treatment is indicated. On the right there is satisfactory explanation that the main greater saphenous vein has already been stripped in the past and that treatment of the residual saphenous vein would not significantly impact the patient's revascularization options. Our physician reviewer found that the enrollee's condition meets Medicare criteria for these services. 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 been met. Therefore, we decided that the Plan has to pre-approve unilateral (right) greater saphenous vein ablation and bilateral stab avulsions for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transitional care provided on March 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for transitional care. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 had network providers available who could have provided 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 transitional care provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair accessible ramp for the home.
You asked the Plan to pre-approve a wheelchair accessible ramp for the home. You say that the ramp is necessary for the enrollee to get in and out of the home for necessary appointments and instrumental activities of daily living. The Plan denied your request. The Plan says this item does not meet the definition of durable medical equipment and is not used in the home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use
inside the home. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Also, Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a wheelchair accessible ramp for the home.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 27, 2020, to November 30, 2020.

You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the claim was denied for an invalid type of bill.

The Plan must follow Medicare rules. Medicare rules say that home health services must be reported correctly.

The claim was not submitted with the correct type of bill. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from November 27, 2020, to November 30, 2020.