Persius/hicric huggingface dataset:
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 you need a higher level of care than a skilled nursing facility for treatment of your acute respiratory failure with hypoxia. The Plan denied your request. The Plan says LTACH services are not medically necessary. The Plan says that you can safely receive the care needed in another 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the implants (D7953) and additional extractions (D7140) provided on June 19, 2020. You asked the Plan to pay for the implants and additional extractions. You say that you would like reconsideration because you fell and knocked out your teeth which should be considered a medical issue. The Plan denied your request. The Plan says these services are not Plan covered benefits. 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 implants (D7953) and additional extractions (D7140) provided on June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you are an extreme fall risk.The Plan denied your request. The Plan says you are receiving adequate and necessary intensive rehab in the inpatient rehab facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you do not require skilled nursing or therapy services with the specialized skill, knowledge and judgment of a skilled professional nurse or therapist required to provide treatment in a SNF. Skilled nursing or therapy services are not required on a daily basisin a SNFsetting.Yourneeds can be met safely and effectively in yourcurrent facility at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health.You asked the Plan to pre-approveinpatient mental health. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any aggressive behaviors. You were being cooperative and compliant.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing.

You asked the Plan to pay for the pharmacogenetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says to report a Comprehensive Genomic Profile, service providers should use current procedural terminology code 81479.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the pharmacogenetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 diagnostic testing provided on July 23, 2020.
You asked the Plan to pay for the testing. You say that this service should be covered based on the CARES Act that was enacted on March 27, 2020. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 diagnostic testing provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care (99222, 99223) and the subsequent hospital care (99232) provided on September 3, 2020.
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 provided are not payable for the diagnosis indicated. Additionally, the services were rendered by an out of network provider.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for these services by a contract provider. The file does not show that the plan provided notice that these services would not be covered. Under Medicare rules, this means that the inpatient hospital care provided is considered approved by the plan. Therefore, we decided that the Plan has to pay for the initial hospital care (99222, 99223) and the subsequent hospital care (99232) provided on September 3, 2020.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on March 2, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was billed with an incorrect type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on March 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound.

You asked the Plan to waive the copayment for the ultrasound. You say that you were informed there would be no charge if the ultrasound pertained to your mammogram. You say that you cannot pay this and would like the bill canceled. The Plan denied your request. The Plan says the copayment 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 $110 copayment for each Medicare-covered radiological diagnostic service.

You have been asked to pay $108.62, which is less than the standard $110 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The ultrasound is considered a diagnostic service, which applies a copayment. 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 ultrasound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical boot provided on October 19, 2020.
You asked the Plan to pay for the surgical boot. The Plan denied your request. The Plan says this item is not a covered benefit.
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 the surgical boot provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment provided on September 10, 2020.
You asked the Plan to pay for the personal protective equipment. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit.
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 personal protective equipment provided on September 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health care visits.

You asked the Plan to waive the copayments for the outpatient mental health care visits. You say that there was an overcharge error of a $25 copayment twice. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each in-network Medicare-covered individual or group therapy visit.

You have been asked to pay a $25 copayment for the outpatient mental health care visit on each date of service. The outpatient mental health care visits fall within the "Outpatient mental health 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 copayments for the outpatient mental health care visits.

Please contact the Plan if you have any questions about prior billing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory services provided by an out-of-network provider on October 15, 2020.
You asked the Plan to pay for the office visit and laboratory services. You say that the patient was an established patient at the time of service. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 the office visit and laboratory services provided by an out-of-network provider on October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the botox injections provided on July 28, 2020 and October 26, 2020.
You asked the Plan to waive the coinsurance for the botox injections. You say that the charges exceed the past visits. You say that the charges should be reconsidered. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% for each Medicare-covered Part B drug obtained in an in-network provider's office or outpatient setting. The enrollee has been asked to pay a total of $486.89 for the botox injections.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 28, 2020
Botox Injection
$1,219.01
20%
$243.81
October 26, 2020
Botox Injection
$1,215.41
20%
$243.08
TOTAL:
$486.89
The botox injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the botox injections provided on July 28, 2020 and October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the drug testing.

You asked the Plan to waive the copayment for the drug testing. You submitted your bill for review. 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 $10 copayment per day, per provider, for in-network Medicare-covered laboratory services.

You have been asked to pay a $10 copayment for the drug testing on each date of service. The drug testing falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 drug testing.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a knee orthosis (L1852).

You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says that there was no documentation of laxity of instability of the knees.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered if there is physical exam documentation of knee instability.

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 orthosis. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has a meniscal tear on the left as well as a positive McMurray's test with instability on the right. There was also some laxity on the right with borderline Lachman and anterior drawer on the right. In this case, there is primary source documentation of an examination that indicates the ambulatory enrollee has instability and laxity in the right knee. The elements of the local coverage determination are satisfied. Therefore, coverage of the requested knee orthosis is recommended.

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 orthosis have been met. Therefore, we decided that the Plan has to pre-approve a knee orthosis (L1852).

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on June 22, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the physician's service. 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 physician's services that you provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prochlorper 10mg tablet medication.

You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication in this scenario is covered by a pharmacy benefit; however, the enrollee does not have a pharmacy benefit with the Plan.

The Plan must follow Medicare rules. Medicare rules say that coverage is provided for oral anti-emetic drugs that are used only as full replacement for intravenous dosage forms of a cancer regimen when additional criteria are met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Specifically, oral anti-cancer medication has not been prescribed for the enrollee, and the requested amount of anti-emetics to be dispensed exceeds what may be covered by Medicare Part B. The request is for 30 tablets every six hours as needed. However, Medicare Part B coverage is limited to one dose before chemotherapy starts, then continued every six hours for up to two days which would be fewer than 30 tablets. Continued use of the drug beyond that time would not be eligible for Part B coverage, but could be covered by the Part D benefit. Therefore, we decided that the Plan does not have to pre-approve the Prochlorper 10mg tablet medication.