Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional outpatient PT visits.

You asked the Plan to pre-approve the PT visits. You say that you were approved previously and have now been denied. The Plan denied your request. The Plan says currently the additional visits are not necessary and if PT is necessary beyond the 12 visits, updated clinical can be submitted for evaluation.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy for this condition and the plan approved additional therapy. Without the outcome of the approved therapy the records do not demonstrate at this time that the unique skills of a professional therapist will be required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have already been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional outpatient PT visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) provided on June 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that the facility should have obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent or emergent.

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 psychotherapy (90837) provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.

You asked the Plan to waive the copayment for the ambulance services. You say that the hospital and doctor did not charge you. You do not think that you owe the ambulance bill. The Plan denied your request. The Plan says you were charged this cost sharing 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 $270 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $270 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation therapy provided on July 21, 2020, to July 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for electrical stimulation therapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 electrical stimulation therapy provided on July 21, 2020, to July 28, 2020 by an out of network (OON) provider.
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 enrollee requires an intensive rehab therapy program. The Plan denied your request. The Plan says the enrollee's needs can be met 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 physician reviewer found that the enrollee was admitted to the acute hospital for left hemiparesis and was treated for a stroke. Her medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7210, D6795, D6254) received from August 6, 2020 to September 23, 2020.
You asked the Plan to pay for the services. You say that you would like a reimbursement check. The Plan denied your request. The Plan says the claim processed appropriately according to your 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, D6795 and D6254 are not among those covered under this benefit, so you owe the full amount for these services. D7210 is covered by the plan, but it was provided by an out-of-network provider. Out-of-network dental services are subject to specific cost-sharing guidelines. Therefore, we decided that the Plan does not have to pay for dental services (D7210, D6795, D6254) received from August 6, 2020 to September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient services provided on September 15, 2020.

You asked the Plan to waive the deductible for outpatient services. You say that this was the first appointment with a new provider, and you were informed your insurance was approved. You say that there was no discussion that this visit was out-of-network and would result in costs. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $950. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. 

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" and "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $950 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time outpatient services was received on September 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for outpatient services provided on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says a continued hospital stay is needed to get better.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure, third degree heart block, acute respiratory failure, and aortic stenosis 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. 

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a portable gaseous oxygen system (E0431) and an oxygen concentrator (E1390) rented on July 15 to August 15, 2020.
You asked the Plan to waive the coinsurance for a portable gaseous oxygen system and an oxygen concentrator. You say that you should not be responsible for this bill. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for Medicare-covered durable medical equipment. You have been asked to pay a monthly charge of $18.70, or 20% of the Medicare-allowed monthly amount of $93.49, for a portable gaseous oxygen system and an oxygen concentrator. A portable gaseous oxygen system and an oxygen concentrator fall within the "Durable Medical Equipment (DME) and Related 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 coinsurance for a portable gaseous oxygen system (E0431) and an oxygen concentrator (E1390) rented on July 15 to August 15, 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 you want to return to being independent as quickly
as possible. The Plan denied your request. The Plan says you do not need intensive rehab to return to your prior
level of functioning.

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 hospital for dizziness, falls, orthostatic hypotension and progression of
Parkinson's disease. Your medical problems are stable. There are no complex nursing needs. You do not
require treatment by multiple therapies, including physical or occupational therapy, in an intensive
rehabilitation therapy 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared
for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says that the
enrollee's medical needs are being met in the current acute 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. 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. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the standardized eye exam to evaluate the visual field (92083) and ultrasound of the eyes (76514) provided August 12, 2020.

You asked the Plan to waive the copayment for the eye exam and ultrasound. You say that your vision services for Glaucoma screening should be covered in full. The Plan denied your request. The Plan says the copayments were 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 $20 copayment for an eye exam to diagnose and treat diseases and conditions of the eye. The Plan contract also says that you must pay a $20 copayment for Medicare-covered outpatient diagnostic procedures or tests. 

You have been asked to pay a total of $32.27 in cost-shares for the eye exam and ultrasound. The eye exam falls within the Vision care benefit category. The ultrasound falls in the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The total cost-share for each service is less than or equal to the copayments required by the Plan. 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 standardized eye exam to evaluate the visual field (92083) and ultrasound of the eyes (76514) provided August 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Northera Capsule 200mg.

You asked the Plan to pre-approve Northera Capsule. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Northera Capsule 200mg.

Benefits for Northera Capsule 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for additional testing with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the request is not urgent or emergent in nature.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for additional testing with an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 testing provided to the enrollee on November 1, 2020.
You asked the Plan to pay for the testing. You say that this is an incorrect denial. The Plan denied your request. The Plan says that respiratory infectious agent detection - CPT code 87633 - is non-covered by Medicare and is excluded from coverage.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not substantiate their denial. They cited Local Coverage Article: Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (A57579) and Local Coverage Determination (LCD): MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (L37764) in their denial. Neither of these citations are valid for the state of Texas for Medicare Part B. The plan has not provided a valid denial reason. COVID-19 testing is reasonable for the enrollee's diagnoses - Z20.9 (contact with and suspected exposure to unspecified communicable disease), B34.2 (coronavirus infection, unspecified), R05 (cough) and R11.0 (nausea). Therefore, we decided that the Plan has to pay for COVID-19 testing provided to the enrollee on November 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on September 29, 2020.

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 this should have been reported with CPT 81479.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 the Guardant360 test provided to the enrollee on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radicava (J1301).

You asked the Plan to pre-approve Radicava. You say that Radicava is medically necessary. The Plan denied your request. The Plan says this drug is not medically necessary.

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 Radicava. Our reviewer says that Radicava is not medically necessary. Our physician reviewer found approval of Radicava requires documentation of normal pulmonary function on pulmonary function testing. Records were not provided to show pulmonary function testing. Additionally, the condition needs to have been present for two years or less. Current records are not clear and suggest the enrollee is outside the two-year window. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Radicava have not been met. Therefore, we decided that the Plan does not have to pre-approve Radicava (J1301).