Persius/hicric huggingface dataset:
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that you were admitted to an acute care hospital for weakness and slurred speech. Medical conditions 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. Although you require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 31, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim has not been processed by the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan
confirmed that they have not received an Explanation of Benefits (EOB) from the primary insurer for this
claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer
has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office
visit rendered on December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from August 27, 2020, to September 4, 2020.

You asked the Plan to waive the copay for the services provided. You say that you are having a hard time paying your bills. The Plan denied your request. The Plan says you are responsible for the copay.

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 $350 copay per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $350 copay each day for 5 days of inpatient care. The services fall within the inpatient hospital care 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 copay for the inpatient hospital services provided from August 27, 2020, to September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treadmill (A9300) purchased on August 13, 2020.

You asked the Plan to pay for the treadmill. You say that you would like the Plan to cover and reimburse $150 for the treadmill. You purchased it in August, but you did not receive it until late September. You feel it would be the best use of your benefit because you have not been able to get to a gym in a long time due to the current pandemic. The Plan denied your request. The Plan says the benefit allowance was extended to include reimbursement for the purchase of fitness equipment due to the pandemic; however, this change was effective starting October 1, 2020. Purchases made before October 1, 2020, are not eligible for reimbursement under the temporary COVID-19 Policy.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 toward the cost of a membership in a qualified health club or fitness facility, instructional fitness classes, participation in some wellness programs, nutritional counseling and acupuncture. The Plan chose to extend this under a temporary COVID-19 Policy due to the current pandemic. Under this policy, which became effective on October 1, 2020, the $300 wellness allowance may be used toward the purchase of exercise equipment that you can use at home.

The Plan's rules for coverage of gym benefits have not been met because the treadmill was purchased before the change in policy took place on October 1, 2020. Therefore, we decided that the Plan does not have to pay for the treadmill (A9300) purchased on August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on January 17, 2021.

You asked the Plan to pay for the subsequent hospital care. You say that the enrollee's hospice coverage ended on January 14, 2021, and this claim should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on January 14, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on January 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments). You can find this rule at 42 CFR Section 422.111. The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $250 copayment for each ambulance trip. You can find this information on page 61 of the Plan's Evidence of Coverage (EOC).
Explanation of decision
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 your benefit said that it was supposed to be a free ride but now you've gotten a bill for $250. You're not paying it. 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 $61 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you further for the oxygen concentrator rendered on
September 21, 2020.
You asked the Plan to reimburse you further for these services. You say that you should receive more
reimbursement. The Plan denied your request. The Plan says the claim was reimbursed 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 20%
coinsurance for Medicare-covered durable medical equipment.
Review of the file shows that you received an oxygen concentrator on September 21, 2020. The Medicare
allowed amount for these services was $103.47. The Plan is only able to reimburse you based on the Medicare
allowed amount. The Plan reimbursed you less the 20% coinsurance, for a total of $82.78. 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 reimburse you further for the oxygen concentrator rendered on September 21, 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) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan has no contractual obligation to cover services that are not reasonable or
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited (problem-focused) oral evaluation (D0140) provided on July 14, 2020, and a retreatment of a previous root canal therapy (D3348) provided on July 15, 2020.

You asked the Plan to pay for the evaluation and root canal treatment. You say that these services were necessary and should be covered as you pay extra for the additional dental coverage. The Plan denied your request. The Plan says retreatment of root canals is not covered by Medicare or by the supplemental dental benefit. The limited evaluation is a covered service; however, this type of evaluation may only be covered once per plan year. You had a previous limited exam in April 2020, which was paid for by the Plan. Therefore, payment cannot be made for either service on the dates in question.

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. The Plan can cover one limited exam to evaluate a problem per plan year.

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 or are requested in a frequency that exceeds what is allowed by this benefit. Therefore, we decided that the Plan does not have to pay for a limited (problem-focused) oral evaluation (D0140) provided on July 14, 2020, and a retreatment of a previous root canal therapy (D3348) provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on February 3, 2021.
You asked the Plan to waive the copayment for the chest x-ray. You say that you did not have the urine test done. 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 $45 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $45 copayment for the chest x-ray. The chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed for the chest x-ray and not for the urine test.
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 chest x-ray provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found he enrollee has right knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve audiologist services to be provided by an out of network provider.
You asked the Plan to pre-approve audiologist services with an out of network provider. You say that you cannot get an appointment with the in-network provider until June. The Plan denied your request. The Plan says appointments were available with the in-network audiologist before available with the out of network audiologist.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve audiologist services to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on December 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77002 is not supported.
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 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). We find that CPT code 77002 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 pay for the imaging services rendered on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 3, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 3, 2020.