Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection (27096).

You asked the Plan to pre-approve SI joint injection. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of an SI joint injection have not been demonstrated in peer-reviewed literature.

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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 76-year-old woman has chronic low back pain, hip pain and Sacroiliitis. There is no physical examination of the SI joint on the chart. Performing a physical examination prior to any intervention is the standard of care. This has not been done. Therefore, the request 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 SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on December 1, 2020.

You asked the Plan to waive the copayment for an injection. You say that you did not know that you would be charged $295 for this injection. The Plan denied your request. The Plan says the correct copayment has been 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 a $295 copayment for outpatient surgery. 

You have been asked to pay a $295 copayment for an injection. The injection that you received is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve these services. You say that you have several doctor's appointments and no alternative transportation. The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says you do not meet criteria for SNF services. Your needs can be met at a lower level of care such as at home with home care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, that you received oral medications and insulin. You had stable vital signs. You were treated for pain with effect. You were to follow up at an outpatient wound clinic. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the acute hospital. You were at a contact guard assist to stand by assist level for functional mobility including gait to 25 feet with a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve separate payment for Cinacalcet.

You asked the Plan to pre-approve separate payment for Cinacalcet. You say that this drug is medically necessary. The Plan denied your request. The Plan says this medication is not covered under Medicare Part B as an individually billed service when provided at dialysis facility for the diagnosis End Stage Renal Disease.

The Plan must follow Medicare rules. Medicare rules say that ESRD facilities are responsible for furnishing drugs directly or under arrangement. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of separate payment for Cinacalcet have not been met. Therefore, we decided that the Plan does not have to pre-approve separate payment for Cinacalcet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for annual wellness visit (G0439) provided December 14, 2020.
You asked the Plan to pay for the annual wellness visit. You say that this service was for your annual wellness visit that has always been paid in full by Medicare. You are entitled to a Wellness visit each year by Medicare and this is against Medicare rules. This needs to be corrected. The Plan denied your request. The Plan says the plan has already approved and paid for an annual wellness visit coded as G0439 on date of service January 27, 2020.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for annual wellness visit (G0439) provided December 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on September 6, 2020.

You asked the Plan to pay for the self-administered drug. You say that this should be covered. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.

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 pay for the self-administered drugs provided in an outpatient setting on September 6, 2020.

Benefits for the self-administered drug 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.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 patient is a 62-year-old female who was admitted to the current acute care hospital with cardiac arrest. The patient appears to be gradually improving but has not yet had any weaning trials to determine long-term ventilator needs which can be safely performed at the current facility. The patient does not require services at the LTACH that are not already available. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when weaning has been fully attempted and long-term needs are more clear. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 92-year-old female with acute hypoxic respiratory failure. While you have identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and 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 admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the requested care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have 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 in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on December 16, 2020.

You asked the Plan to pay for drug tests. You say that these tests were requested by the treating physician and provided in good faith unbeknownst to the fact that the enrollee's coverage required prior authorization. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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. Medicare rules say that plans can require enrollees to get care from network providers.

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 provide a copy of the applicable Evidence of Coverage (EOC) for this date of service. Without this information, we cannot determine whether this Plan has any prior authorization or network lock-in rules which may apply to these services. Therefore, the Plan has not shown that its decision to deny payment on the basis of this provider being out-of-network and not obtaining prior authorization is correct or justified according to Medicare rules and the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pay for drug testing provided on December 16, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided by a student practitioner on July 8, 2020.

You asked the Plan to pay for lab services. You say that you want this claim to be paid. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is a student which is not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for any service furnished by a student. 

We looked at the file and Medicare rules. These services were provided to you by a student; therefore, they are not payable by Medicare. Based on this information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided by a student practitioner on July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continuation of SNF care. You say that you continue to need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled therapy service needs and no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on December 4, 2020.

You asked the Plan to pay for the self-administered drugs. You say that this should be covered. You say that the enrollee was not allowed to bring her medication with her to the hospital. You also say that this has been covered in the past. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

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 pay for the self-administered drugs provided in an outpatient setting on December 4, 2020.

Benefits for the self-administered drugs 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the computed tomography (CT) scan of the chest (71250) provided November 30, 2020.

You asked the Plan to waive the co-payment for the CT scan of the chest. You say that you believe you have been billed incorrectly as you say you get this procedure all the time without any cost share. The Plan denied your request. The Plan says they confirmed the provider billed you correctly and the cost share processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 co-payment for outpatient diagnostic tests.

You have been asked to pay a total cost share of $110.85 which is less than the required $325 co-payment for the CT scan of the chest. This service falls within the outpatient diagnostic tests 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 co-payment for the computed tomography (CT) scan of the chest (71250) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided in an urgent care center on November 22, 2020.

You asked the Plan to pay for services provided in an urgent care center. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes.

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 CPT code S9088 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of services provided in an urgent care center have not been met. Therefore, we decided that the Plan does not have to pay for services provided in an urgent care center on November 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the PT and OT provided from May 28, 2020, through June 30, 2020.

You asked the Plan to pay for the PT and OT. You say that you were not aware that continued therapy was not covered. The Plan denied your request. The Plan says did not meet medical necessity criteria for continuation of services. The enrollee's physical therapy plan of care was custodial in nature.

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 pay for the PT and OT. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee started therapy as early as February 11, 2020. By May 29, 2020 she should have been independent with a home exercise program. The additional physical therapy sessions beyond May 29, 2020 are considered excessive and not an appropriate duration and frequency for the enrollee's medical condition. 

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 and OT have not been met. Therefore, we decided that the Plan does not have to pay for the PT and OT provided from May 28, 2020, through June 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda tablets.

You asked the Plan to pre-approve self-administered drugs. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.

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 Latuda tablets.

Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.