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

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided 
from August 27, 2019 to November 15, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided 
from August 27, 2019 to November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 18, 2019 to May 1, 2019 by out of network provider.You asked the Plan to pay forpractitioner visits. You say that the enrollee had no choice of which provider rendered service, and these services were medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to getcare 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 forthe medical services provided on April 18, 2019 to May 1, 2019 by out of network provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the interpretation and report of electrocardiogram (EKG) findings provided on May 25, 2019 billed along with emergency department evaluation and management (E/M) services.You asked the Plan to pay forthe EKG interpretation and report. You say that this should be separately paid.The Plan denied your request. The Plan says that since there is no documentation of a full report only that the report was reviewed, this is not eligible for payment.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 93010 is Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pay for the EKG interpretation and report. Our reviewer says that the documentation supports the billing of this code. Our reviewer found the documentation contains a physician interpretation and report of the EKG that was performed on this date of service. This is shown to be more than just a review of the findings.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the EKG interpretation and report have been met.Therefore, we decided that the Plan has to pay forthe interpretation and report of electrocardiogram (EKG) findings provided on May 25, 2019 billed along with emergency department evaluation and management (E/M) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 13, 2019 by out of network provide.You asked the Plan to pay for physical therapy. You say that our physical therapist treated the enrollee in good faith and provided him with the medical care he required.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider, The physician, is also out-of-network 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 for the medical services provided on September 13, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Humira Kit 40MG/0.8.You asked the Plan to pre-approvea Humira Kit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says a Humira Kit is not covered under the enrollee's Medicare Part B benefit. The plan believes the enrollee's pharmacy benefit manager is Express Scripts.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-approvea Humira Kit 40MG/0.8.Benefits for a Humira Kitmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that the enrollee is ready for discharge from the hospital.The Plan denied your request. The Plan says the admission is not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with hypercapnic respiratory failure requiring vent support. He needs maximal assist with bed mobility, total assist with lower body dressing, and a Hoyer lift for transfers. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the enrollee would benefit from an IRF stay to optimize his functional level prior to placement in an assisted living facility.The Plandenied your request. The Plansaysthe enrollee is medically stable and does not requires an intensive rehab program.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 basedon Medicare guidelines. Our physician reviewer found the enrollee is a 75 year old male seen by his PCP for a decline in function. He has had multiple falls. His current level of function is ambulating with a cane, supervision with bed mobility, supervision with transfers, minimal assist with ambulation, and supervision with ADLs. Based on available records, the patient does not meet criteria for coverage of IRF. The patient is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe injection of therapeutic drugs (D9610).You asked the Plan to pre-approvethe dental service. The Plan denied your request. The Plan says the requested dental service is not listed as a covered service.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 dental service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe injection of therapeutic drugs (D9610).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveGammagard liquid for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is not enough support for Gammagard Liquid for use in the treatment of IgM-paraprotein and progressive/aggressive predominantly sensory polyneuropathy.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the criteria above are not met as the IVIG is not being intended tobe used for an FDA approved indication. There are no clinical studies demonstrating benefit with IVIG for these specific individuals with anti-GAD antibody medicated neuropathies. Studies in the 1990s by Dalakas et al. failed to demonstrate statistically significant improvement of neuropathy scores in patients treated with IVIG vs. placebo.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 Plandoes not haveto pre-approveGammagard liquid for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says there are no skilled nursing needs or skilled therapy needs that require the requested level of care. The plan says that the enrollee is not medically stable for transfer to an alternate level of care. The plan says that the enrollee does not meet the guidelines for coverage of IRF care, as the clinical information indicates that the enrollee's needs can besafely met in the current hospital setting.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 thecase 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual wellness visit you received on September 23, 2019.You asked the Plan to pay forthe annual wellness visit. You say that the service was not billed correctly.The Plan denied your request. The Plan says the benefit was exhausted for the routine service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The file shows that you received an annual wellness visit on September 23, 2019. You last received an annual wellness visit on April 26, 2019. We looked at the file and the rules. Your plan only covers annual wellness visits once every 12 months. Based on this information, we decided that the Medicare coverage rules have not been met. Therefore, we decided that the Plan does not have to pay forthe annual wellness visit you received on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on August 26, 2019.You asked the Plan to pay for the services. You say that you did not know the provider was out-of-network.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 services at issue in this appeal. 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 forthe medical services provided to you by an out-of-network provider on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B injections provided on May 10, 2019 and July 8, 2019.You asked the Plan to waive the cost share forthe Part B injections. You say that you were under the impression that since the injections were approved, they would be covered.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 there is a $250 in-network deductible that applies towards Medicare Part B injections and 20% coinsurance for each Medicare-covered Part B drug obtained in an in-network provider's office or outpatient setting after the yearly deductible is met. The Part B injections you asked the Plan to waive the cost share for falls within the "Medicare Part B prescription drugs" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 in-network deductible that applies towards Medicare Part B injections and 20% coinsurance for each Medicare-covered Part B drug obtained in an in-network provider's office or outpatient setting after the yearly deductible is met. The record shows $218 was applied towards the $250 in-network deductible,which meets the $250 in-network deductible amount. The original allowed amount for the Part B injection is $5,006.40. The remaining allowed amount after the deductible was applied is $4,788.40. ($5,006.40 -$218 = $4,788.40).After the deductible is met, you owe 20% of the remaining allowed amount. Therefore, you owe a coinsurance amount of $957.68. ($4,788.40 x 20% = $957.68). The total amount you owe on May 10, 2019 is $1,175.68. ($218 + $957.68 = $1,175.68). You have also been asked to pay $1,013.04 which is 20% of the allowed amount for the Part B injection on July 8, 2019. The allowed amount is $5,065.20. ($5,065.20 x 20% = $1,013.04). This cost sharing is a contractual obligation that had not been met at the time the PartB injectionswere received on May 10, 2019 and July 8, 2019.Therefore, we decided that the Plan does not have to waive the cost share forthe Part B injections provided on May 10, 2019 and July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for "the beneficiary". You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs this so she can live.The Plan denied your request. The Plan says the enrollee's 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 physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COPD and pneumonia. 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.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-approvelong term acute care hospital (LTACH) services for "the beneficiary".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on May 5, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We findthat CPT code 99152 is not supported in the medical record. Specifically, the record does not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on May 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvetransforaminal epidural injection.You asked the Planto pre-approve the injection. You say that this is medically necessary to help you walk.The Plan denied your request. The Plan saysthe correct amount of pain relief was not documented.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the continuation of epidural steroid injections every 3 months. The requested injection is not medically reasonable or 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 the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetransforaminal epidural injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz XR 11 MG tablets.You asked the Plan to pre-approve Xeljanz XR tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Xeljanz XR tablets are not covered under the enrollee's Medicare Part B 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-approveXeljanz XR 11 MG tablets.Benefits for Xeljanz XR tablets may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegradient compression stockings (HCPCS A6530) for the enrollee.You asked the Plan to pre-approvethe compression stockings. You say that this is medically necessary to treat venous insufficiency.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into acovered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvegradient compression stockings (HCPCS A6530) for the enrollee.