Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar laminotomy and acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee did physical therapy at another facility. You say that the enrollee has tried conservative management and steroid injections. You also say that having the surgery would help with the leg pain as a final resort. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan says that the procedure is currently approved as an ambulatory procedure. The Plan also says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is undergoing a planned procedure. The reviewer found that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The reviewer found that the provider's notes indicate they recommended an overnight admission for observation before sending him home. The reviewer found that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the file does not show that the enrollee's necessary hospital care would span two midnights. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminotomy and acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), preventive procedure (D1999), and periodontal maintenance (D4910) provided on March 11, 2021 by an OON provider.

You asked the Plan to pay for the topical application of fluoride varnish, preventive procedure, and periodontal maintenance. You say that you have never been informed of certain provider locations being in-network and others being OON. The Plan denied your request. The Plan says your plan does not cover services from a provider who is not in-network. The Plan also says that the provider contacted the Plan on the date these services were rendered to verify eligibility and was informed that the provider was not a contracted provider for your dental insurance 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), preventive procedure (D1999), and periodontal maintenance (D4910) provided on March 11, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift chair (E1399).

You asked the Plan to pre-approve the lift chair. You say that the lift chair is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

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 plan can cover a seat-lift mechanism if it is requested and is medically necessary. The item requested is a lift chair. The chair is never covered. Therefore, we decided that the Plan does not have to pre-approve a lift chair (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 8, 2020, by an OON provider.

You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 drug testing provided on January 8, 2020, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 31, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you were never informed by the hospital that you would be charged for this service. You say you have never paid a copayment for this type of procedure. 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office of at a free-standing facility (such as a radiology center or medical clinic). 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 $155 copayment for the ultrasound.

You have been asked to pay a $93.53 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services or 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 ultrasound provided on December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) service provided from April 7, 2021, to April 9, 2021.

You asked the Plan to pay for the SNF services provided from April 7, 2021, to April 9, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled care on the dates of service in this case.

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 provided from April 7, 2021, to April 9, 2021. 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 provided from April 7, 2021, to April 9, 2021, have not been met. Specifically, the file shows that the enrollee did not require daily skilled service. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) service provided from April 7, 2021, to April 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arformoterol 15 mcg/2 ml solution.

You asked the Plan to pre-approve arformoterol. You say that you need this medication now. The Plan denied your request. The Plan says you have not tried and failed the preferred drug Perforomist (formoterol).

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 arformoterol. Our reviewer says that the requested drug, arformoterol, is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Performist before they will approve the requested medication. The reviewer found that you have not tried and failed the required drug. There is no documentation provided indicating that the Pan's required drug would likely be less effective and/or likely have adverse effects for you. Therefore, the reviewer found that the requirements for step therapy 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 arformoterol have not been met. Specifically, the file does not indicate that you have tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve arformoterol 15 mcg/2 ml solution.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the receiver/monitor), for use with therapeutic glucose continuous monitor (CGM) system (K0554) provided February 22, 2021.

You asked the Plan to pay for the CGM receiver/monitor. You say that see attached documentation to review and reprocess the claim as this CGM monitor was very necessary for the enrollee to improve their quality of life. The Plan denied your request. The Plan says this provider was not certified/eligible to be paid for this procedure/service on this date of service.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. 

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the CGM receiver/monitor have not been met. Therefore, we decided that the Plan does not have to pay for the receiver/monitor), for use with therapeutic glucose continuous monitor (CGM) system (K0554) provided February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 18, 2021, and February 19, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you only had your blood drawn on February 18, 2021 and it is not your fault that the tests were run on different days. 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 a $10 copayment for laboratory tests. The medical records show that you received laboratory services on February 18, 2021. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment.

The medical records show that you received laboratory services on February 19, 2021. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. 

The total amount you owe is: $20. 

You have been asked to pay the total copayment amount of $20 for laboratory services. Laboratory services fall 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 laboratory services provided on February 18, 2021, and February 19, 2021.
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 is medically necessary. The Plan denied your request. The Plan says you can safely receive the services that you need at a lower level of care.

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 reviewer found that while the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer also found that here 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. Specifically, the file does not indicate that the enrollee would and benefit from an intensive rehabilitation therapy program provided in an IRF. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visits provided from December 14, 2020, to December 28, 2020.

You asked the Plan to pay for the psychotherapy visits. You say that you could not find a therapist due to the coronavirus and this was the only provider you could find that would take you as a patient. The Plan denied your request. The Plan says the services were rendered by a non-Medicare accepted type of provider.

The Plan must follow Medicare rules. Medicare rules say that the rules state that to receive payment for covered Medicare items or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule in 42 Code of Federal Regulations (CFR), Section 424.505.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy visits have not been met. This provider is a Licensed Mental Health Counselor (LMHC). LMHCs are not eligible to enroll in Medicare which means this provider is not payable. Therefore, we decided that the Plan does not have to pay for the psychotherapy visits provided from December 14, 2020, to December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 6, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that you were unable to get the authorization due to a short period. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 drug testing provided on October 6, 2020 by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on May 5, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that your dentist office told you that the services were not covered under your plan because the provider is out-of-network. You also say that prior to signing up with the Plan, you called to verify that your dentist was in-network and were told they were. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 first intraoral periapical x-ray (D0220) provided on May 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 12, 2020.

You asked the Plan to pay for the laboratory services. You say that the documents should be reviewed, and the claim should be processed toward payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes (97110) provided October 1, 2021.

You asked the Plan to pay for therapeutic procedure. You say that many of the requested services in 2020 were not available on an outpatient basis secondary to the recent COVID-1999 Virus pandemic. Please review all attached documentation supporting this request and process the claim for payment. The Plan denied your request. The Plan says the records do not support the billed service.

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 97110 is therapeutic procedure, on one or more areas, each lasting 15 minutes. 

We find that CPT code 97110 is not supported in the medical record. Specifically, there is a more appropriate CPT, HCPCS and/or REV code for the service provided. The records submitted indicate that physical therapy was provided in the enrollee's home. There is a more appropriate HCPCS (healthcare common procedure coding system) code that should be used to bill for the services. Additionally, while a total time in the home was documented, the documentation does not indicate the time spent providing the billed service. Therefore, the billed code, units and appended modifiers cannot be verified. Based on this information, we decided that Medicare rules for coverage of therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes (97110) provided October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nephrology visit provided on April 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nephrology visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 nephrology visit provided on April 27, 2021 by an out-of-network (OON) provider.