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

We decided that the Plan does not have to waive the copayments for the laboratory services provided on May 9, 2019 and the office visit provided on May 15, 2019.
You asked the Plan to waive the copayments for the laboratory services and office visit. You say that the laboratory services were part of a wellness visit. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare-covered laboratory test from a Tier 2 provider and a $10 copayment for each Medicare-covered, Tier 2, primary care doctor visit. You have been asked to pay a $20 copayment for the laboratory services and a $10 copayment for the office visit. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for hypothyroidism, hypercholesterolemia and atherosclerosis during the office visit.
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 copayments for the laboratory services provided on May 9, 2019 and the office visit provided on May 15, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility services provided to the enrollee from June 17, 2019 to June 20, 2019.
You asked the Plan to pay for skilled nursing facility services provided to the enrollee from June 17, 2019 to June 20, 2019. You say that this claim should be paid. The Plan denied your request. The Plan says that an incorrect Core Based Statistical Area (CBSA) number for value code 61 was used. Chapter 10 of the Medicare Claims Processing Manual, which is for Home Health Agency Billing, speaks to the requirement of a CBSA when value code 61 is billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were 10 pages in the file submitted. Other than the denial letter there were no medical records or specific explanation of the case itself. The Plan submitted an incomplete case file from which we are unable to substantiate the Plans denial. Therefore, we decided that the Plan has to pay for skilled nursing facility services provided to the enrollee from June 17, 2019 to June 20, 2019.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019 by an out-of-network provider.
You asked the Plan to pay for the anticoagulant management (93793). You say that you would like reconsideration as the service provided was medically necessary. The Plan denied your request. The Plan says the member does not have out-of-network benefits and the service was not authorized.
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 August 13, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing oncology services to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the longer you wait lessens the chance for survival. The Plan denied your request. The Plan says your plan covers providers outside of your network only when your medical needs cannot be met in your 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 pre-approve 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. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve ongoing oncology services to be provided by an out of network provider.
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 the SNF admission. You say that the enrollee would benefit from daily skilled services in the SNF. The Plan denied your request. The Plan says the enrollee's needs are custodial and do not require daily skilled care.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was admitted to the hospital on 1/25 due to shortness of breath, congestive heart failure, and elevated troponins. Her current level of function is ambulating 40 feet with contact guard assist and no assistive device, minimal assist with toileting, contact guard assist with toilet transfers, sit to stand with contact guard assist, stand to sit with contact guard assist, standby assist with bed mobility. Based on available records, the patient does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy. 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 admission 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit and monovisc injection rendered to you on August 23, 2019.
You asked the Plan to waive the cost sharing for these services. You say that you do not feel liable for the copayment. The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist visit for Medicare-covered services and 20% of the Medicare-allowed amount for in-network Medicare Part B-covered drugs.
Review of the file shows that you received a specialist visit on August 23, 2019. You have been asked to pay a $35 copayment for these services. These services fall within the in-network specialist visit for Medicare-covered services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you also received a monovisc injection on August 23, 2019. You have been asked to pay 20% of the Medicare-allowed amount for these services, for a total of $589.51. These services fall within the in-network Medicare Part B-covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $624.51. 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 cost sharing for the office visit and monovisc injection rendered to you on August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections for the enrollee.
You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Hyalgan. Our reviewer says that Hyalgan is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Hyalgan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that because of your medical condition you need the power seat elevation feature to reach items, cabinets, and drawers. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee's recent hospitalization was complicated with worsening kidney failure and heart failure following a heart attack without significant improvement noted in recent days regardless of appropriate acute care services. Transfer to LTACH would not provide any unique or otherwise appropriate services which were not already available and covered in the current setting. Therefore, this request for LTACH services will be considered 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration as you are having problems with your health. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 the enrollee's ongoing care needs include respiratory support with nebulizer treatments, oxygen supplementation, BiPAP, intravenoud antibiotics, surveillance laboratory studies, telemetry monitoring, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nulojix infusions (J0485).
You asked the Plan to pre-approve Nulojix infusions. You say that the service is medically 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 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 Nulojix infusions. Our reviewer says that the service is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Nulojix is medically reasonable and necessary or safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve Nulojix infusions (J0485).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/23/20. The enrollee was seen at the wound center on 1/23/20 with ongoing severe infection with areas of necrosis and large plantar abscess incised and drained. The enrollee had right above the knee amputation on 1/27/20. Based on the documentation provided, 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay foronebone marrow aspiration. We decided that the Plan does not have to pay forone bone marrow aspiration and two autografts. You asked the Plan to pay forthe autografts and bone marrow aspiration. You say thatyou would like reconsideration based on the records submitted.The Plan says that the codes billed are not supported by the medical record. The Plan must follow Medicare rules. The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine in the Plan was correct in denying the request to pay for autografts (20937x2) and bone marrow aspiration (20939x2) provided on August 8, 2019. Our review says that the enrollee underwent a two stage spinal surgery. The anterior stage was performed first, followed by the posterior stage. The operative note for the anterior procedure refers to autologous bone and a bone marrow aspirate, but is silent as to how these materials were obtained and prepared. Therefore, billing for the harvesting of these materials, regardless of the approach, is not supported.Our reviewer found the operative note for the posterior procedure clearly describes the harvesting of bone marrow through a separate incision. The bone marrow was then mixed with particulate bone. How the bone was harvested is not described. Therefore, billing for the harvesting of the bone marrows is supported, but billing for the harvesting of the bone is not.We looked at this coder's review, the fileand Medicare rules. Based on this information, we decided that the Plan has to pay forone bone marrow aspiration. We also decided that the Plan does not have to pay for one bone marrow aspiration and two autografts.If the Plandoes 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/orsend us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650)
You asked the Plan to pay for the orthosis. You say that the records submitted should support the necessity of
the services. The Plan denied your request. The Plan says there is no evidence of an established relationship
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and
management service and there is no evidence of a prior 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 the lumbar-sacral orthosis
(L0650)