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

We decided that the Plan does not have to pay for adjustable folding walker (E0135) provided on October 19, 2020, by an out of network (OON) provider.
You asked the Plan to pay for adjustable folding walker. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained prior to this item being purchased.
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 adjustable folding walker (E0135) provided on October 19, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Ultra Blue test strip.

You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the preferred brand.

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 strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for OneTouch Ultra Blue test strips to be used with your glucometer. The requested service is not the plan's preferred brand. In this case, the plan's preferred glucometer and strip system is different than what the enrollee has been using. The prescriber indicated that it is not medically necessary to use the non-preferred system. Therefore, the requested strips are not medically necessary or reasonable as defined by Medicare rules and the requested service cannot be 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Ultra Blue test strip.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided by an OON provider.

You asked the Plan to pay for the nursing facility care. You say that the facility where the enrollee resides
failed to obtain prior authorization for the medically necessary services. The Plan denied your request. The
Plan says they only cover out-of-network services in limited circumstances. The care provided was not urgent
or pre-approved. It is the responsibility of the provider or facility to verify the enrollee's eligibility and obtain
prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The 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 subsequent nursing facility care (99308)
provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection, coinsurance for surgical supplies, and the copayment for an outpatient surgery provided by a participating provider on September 29, 2020.
You asked the Plan to waive the copayment for an injection, coinsurance for surgical supplies, and the copayment for an outpatient surgery. You say that you were told that this would be only $250. The Plan denied your request. The Plan says the correct cost-sharing amounts have been applied.
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 $40 copayment for Medicare Part B prescription drugs/in-network, a 20% coinsurance for outpatient diagnostic tests/in-network/surgical supplies, and a $250 copayment for outpatient surgery/in-network. You have been asked to pay a $40 copayment for an injection, a 20% coinsurance of the allowed amount for surgical supplies, and a $250 copayment for an outpatient surgery. The total allowed amount is $298.77. The amount you are being asked to pay for surgical supplies is $59.75 ($298.77 x 20% = $59.75). The total amount you are being asked to pay is $349.75 ($40 + $59.75 + $250 = $349.75). An injection falls within the Medicare Part B prescription drugs/in-network benefit category. Surgical supplies outpatient diagnostic tests/in-network/surgical supplies benefit category. An outpatient surgery falls within the outpatient surgery/in-network 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 an injection, coinsurance for surgical supplies, and the copayment for an outpatient surgery provided by a participating provider on September 29, 2020.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 weakness associated with a deltoid tear after recent cervical fusion. 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteopathic services (99204, 98929, 99214, 98927) provided by an out of network (OON) provider.

You asked the Plan to pay for the osteopathic services. You say that you should not be penalized for not knowing that you needed prior authorization to get care out-of-network. The Plan denied your request. The Plan says they do not cover out-of-network care, except in limited circumstances. The services provided were not urgent or pre-approved. No referral was provided by your primary care physician.

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 osteopathic services (99204, 98929, 99214, 98927) provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan downcoded the claim to CPT 99284.

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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the emergency room visit supports a comprehensive history (10 systems), comprehensive exam (10 systems) documentation supports low medical decision making. Therefore, CPT 99284 would be the correct code to report for this service.

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 not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274).

You asked the Plan to reimburse you for the dental services. You say that when you went for your appointment, the office told you they do not accept your insurance. You say that you asked for an itemized bill to submit to your insurance. You also say that you were never told that the dentist did not accept Medicare insurance. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider that has opted out of Medicare.

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, reimbursement cannot not be made for dental services that you receive from a provider that has opted out of Medicare. Therefore, we decided that the Plan does not have to reimburse you for the oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider.

You asked the Plan to pay for nursing facility care. You say that the provider depends on the hospital staff to verify eligibility and obtain prior authorization. You say that the services were medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says the Plan requires the utilization of in network providers.

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 nursing facility care provided by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health speech therapy services, each 15 minutes
(G0153 x 7).

You asked the Plan to pre-approve the skilled services. You say that the speech therapy services are necessary.
The Plan denied your request. The Plan says the speech therapy services are not medically necessary. The Plan
also says that the enrollee has reached their baseline level of functioning.

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 the skilled services. Our reviewer says
that home health speech therapy services are not medically necessary. Our physician reviewer found the
provided documentation does not show that the enrollee has documented skilled speech therapy needs.
Therefore, the reviewer found that ongoing home health speech therapy services are not medically necessary or
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 skilled services have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health speech therapy services, each 15 minutes (G0153 x 7).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

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 covered.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60MG/ML Injection (CPT code J0897).

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Prolia in the setting of osteopenia have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer found the review has determined that the documentation does not support that the Prolia 60MG/ML Injection is medically reasonable or necessary for you for the treatment of osteopenia. The documentation does not support that the Prolia 60MG/ML Injection is safe and effective for you. 

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60MG/ML Injection (CPT code J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown.

You asked the Plan to pay more for the crown. You say that you would like this service to be covered. The Plan denied your request. The Plan says this claim processed correctly, and no additional reimbursement will be awarded.

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 must pay a 70% coinsurance for crowns that are received by an in-network provider, which totals $438.90. Therefore, we decided that the Plan does not have to pay more for the crown.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevespi Aerosphere for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bevespi Aerosphere for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition and are 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 LTACH services.