Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing foroffice visits (99212, 99213, and 99214) and injections (96372 and J0717) provided from  May 17, 2018 to September 19, 2018.You asked the Plan to waive the cost sharing foroffice visits and injections. You say that you believed you would only have an office visit copayment for these services.The Plan denied your request. The Plan says these services processed correctlyThe 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 20% coinsurance for chemotherapy and other drugs covered by Medicare Part Band a $40 copayment for each specialist office visit.You have been asked to pay $160for four office visits(4 visits x $40 = $160)and$1934.88 forinjections($9674.48 total allowed amount x 20% = $1934.89).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 waivethe cost sharing foroffice visits (99212, 99213, and 99214) and injections (96372 and J0717) provided from  May 17, 2018 to September 19, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services (88305, G9785) provided on September 21, 2019 by out of network provider.You asked the Plan to pay forpathology services. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service September 21, 2019.The Plan denied your request. The Plan says the attending providers are non-participating in the member's health plan. The referring provider is also a non-participating provider. The plan did not authorize any services. The services are not considered urgent/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 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 has network providers available who can provide 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 forpathology services (88305, G9785)provided on September 21, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on June 3, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on June 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve800 milligrams Infliximab (Remicade) every 4 weeks.You asked the Plan to pre-approveRemicade. You say that you need medication to manage your symptoms.The Plan denied your request. The Plan says there is no need for the amount and frequency without proper support.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 requestto pre-approve Remicade. Our physician reviewer found that the provider notes state you arehaving progressive increase in symptoms. Infusions were changed to every 4 weeks. Yourweight was recorded as 63kg. Reviewed compendia supports the use of 10mg/kg every 8 weeks for individuals who are no longer responding to 5mg/kg. The requested dose and frequency are not supported by compendia. Therefore, the requested dose is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met.Therefore, we decided that the Plan does not have to pre-approve800 milligrams Infliximab (Remicade) every 4 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device and sheep skin covering.
You asked the Plan to pre-approve a continuous passive motion (CPM) device and sheep skin covering. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CPM.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device and sheep skin covering.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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. ThePlan did not pre-approve the servicesat issue. 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 provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl for the Enrollee.
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 self-administered drugs are not covered.
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 Fentanyl for the Enrollee.
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: 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 services are medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a hip fracture. The fracture has been surgically repaired. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 pay for the oral hygiene instructions (code D1330), topical application of fluoride varnish (code D1206), and periodic oral evaluation (code D0120) provided on August 21, 2019.
You asked the Plan to pay for the oral hygiene instructions, topical application of fluoride varnish, and periodic oral evaluation. You say that these services were needed and were done to remove debris under the lower tooth. You also say that your gums were bleeding when you went into the appointment and they have not been bleeding since. The Plan denied your request. The Plan says oral hygiene instructions (code D1330) and topical application of fluoride varnish (code D1206) are not listed as covered services. The Plan also says that the maximum allowed for oral exams had been met.
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, oral hygiene instructions and topical application of fluoride varnish are not among those covered under this benefit. The contract also clearly states that you are limited to 2 exams per calendar year. The record shows that you received a comprehensive oral evaluation (code D0150) on February 6, 2019 and a limited oral evaluation (code D0140) on February 11, 2019 and your exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (code D1330), topical application of fluoride varnish (code D1206), and periodic oral evaluation (code D0120) provided on August 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services provided to the enrollee from September 3, 2019 to September 30, 2019.
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 required functional G-code/modifier information was not billed appropriately.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The therapy claim was not billed with the appropriate G-code. 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 outpatient therapy services provided to the enrollee from September 3, 2019 to September 30, 2019.
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. The Plan denied your request. The Plan says LTACH admission 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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a septic knee. The enrollee is receiving a course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on July 12, 2019.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. 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 ophthalmological services provided on July 12, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 above. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 1, 2020 with a stroke and right-sided weakness. The physical therapy note dated February 4, 2020 states he needs varied assistance for bed rolling, sitting up, and walking 46 feet with a rolling walker. He has no complex medical, nursing, or rehabilitation needs that require the intensity of services provided at an IRF. He is walking household distances and does not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve the wig. You say that your doctor saw your condition of your hair loss on your head and made the order. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wig have not been met. You have coverage for a wig, but this coverage will only pay for a wig when hair loss is caused by chemotherapy. You are not taking chemotherapy. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 4, 2019. You asked the Plan to pay for the ambulance services. You say that the EMT suggested you go to the ER, so your daughter drove you. The Plan denied your request. The Plan says these services are not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on July 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on September 16, 2019.You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.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, we have confirmed that code the subsequent hospital care has a bundled relationship with code 99232 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on October 4, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not considered urgent/emergent in nature. Services rendered by non-participating providers, require 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 did not pre-approve the services at issue. 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 a hospital outpatient clinic visit provided on October 4, 2019.
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 this is medically necessary care. The Plan denied your request. The Plan says there are no acute medical issues requiring frequent physician oversight or a need for intensive rehab.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 patient is a male who was admitted to the hospital 1/14/20 after wife found him in home shower with new left sided weakness and expressive aphasia. The enrollee was admitted for stroke symptoms but neurology did not feel this was stroke or TIA. 

The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient's functional level does not require this on an intensive rehabilitation facility therapy program level 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 inpatient rehabilitation facility (IRF) admission and services.