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

We decided that the Plan does not have to pre-approve physical therapy with an out of network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy services. You say that the requested OON provider is closer to you than the in-network providers. The Plan denied your request. The Plan says there are in network physical therapy providers who are readily available and accessible to the enrollee.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide physical therapy. The in-network physical therapists that the Plan has referred you to are within 10 minutes of your home address. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve physical therapy with an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OVA1 testing provided on January 11, 2021.
You asked the Plan to pay for the OVA1 testing. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says the claim reports both a right sided ovarian cyst and a cyst with unspecified side. The records provided only show documentation of a right sided cyst. As such, use of the unspecified side as well is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that for codes that specify laterality, the unspecified side diagnosis should be used when the record does not document the side of the condition.
In this case, the record shows that the cyst is right sided. As such, there is no reason for unspecified side to be reported. Therefore, we decided that the Plan does not have to pay for the OVA1 testing provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection provided on January 17, 2021 by an out of network (OON) provider.

You asked the Plan to pay for an injection. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 an injection provided on January 17, 2021 by an out of network (OON) provider.
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 enrollee would benefit from an IRF program. The
Plan denied your request. The Plan says there is no documentation of a need for intensive rehabilitation
services.

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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for surgical treatment of a subdural hematoma. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on February 8, 2021.

You asked the Plan to pay for an x-ray. You say that this was a separate service. The Plan denied your request. The Plan says this cannot be paid separately without a modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on February 8, 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 Synvisc One. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy is covered when specific criteria are met. 

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 Synvisc One. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the criteria requires a 6-month interval before starting another viscosupplementation series, which would be August 23. Therefore, the request is deemed not medically reasonable or necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment panel provided on January 11, 2021.
You asked the Plan to pay for the cardiovascular genetic panel. You say that this testing was needed in order to determine whether more diagnostic surveillance is needed. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation to support Medicare coverage criteria are met.
The progress note from the ordering provider in this case does not document the intent for this testing or provide any information on how the information provided by this test would be used to guide treatment. Without such information, it cannot be determined whether this testing meet coverage criteria. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk assessment panel provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection provided on August 24, 2020.
You asked the Plan to waive the copayment for the facet joint injection. You say that you normally pay a $40 copayment to see this provider. You say that you would not have had this done if you knew there was going to be a different copayment. The Plan denied your request. The Plan says the copayment 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 $250 copayment for Medicare covered surgical services in an outpatient hospital setting.
You have been asked to pay a $250 copayment for the facet joint injection. The facet joint injection falls within the "Outpatient hospital services" benefit category. The facet joint injection is considered a surgical service that was billed by the hospital. 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 facet joint injection provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office services (CPT code 99213) provided on December 9, 2020.
You asked the Plan to waive the copayment for the office services. You say that you received a card stating all out-of-pocket costs are to be waived for in-network telehealth visits. The Plan denied your request. The Plan says that the claim was processed accordingly with your 2020 EOC benefits.
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. the Plan did not provide medical records showing that the services at issue were not a telehealth visit. The Plan also did not provide documentation to show that the billed code, or the service performed does not qualify for the copayment waiver. Therefore, we decided that the Plan has to waive the copayment for the office services (CPT code 99213) provided on December 9, 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the lumbar spine. Our reviewer says that the services are medically necessary. Our physician reviewer found while it is true the enrollee has exhibited no red flags such as weakness or reflex abnormality the fact, he has had radio frequency ablation within the past 2 months would qualify as conservative therapy. Furthermore, the fact a procedure has been performed in the lumbar spine and his symptoms have worsened are causes for some concern. A plain x-ray would not be of benefit in this case however MRI is indicated due to his increasing symptoms and recent procedure in order to be certain there have been no complications such as bleeding, infection etc.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

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: 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 it is felt that IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee has no complex medical needs that require intensive rehab and do not need to be directly under the care of a physician during the therapy services.

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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for congestive heart failure, atrial fibrillation, and respiratory failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or
established patient (D0180), resin-based composite - four or more surfaces or involving incisal angle (anterior)
(D2335), resin-based composite - three surfaces, posterior (D2393) and localized delivery of antimicrobial
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided November
19, 2020.

You asked the Plan to pay for the comprehensive periodontal exam, resin-based composites, and localized
delivery of antimicrobial agents. You say that you did not know the provider was not in the Plan's network. The
Plan denied your request. The Plan says the services were not provided by a network provider and therefore are
not covered.

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 covers the
comprehensive periodontal exam, resin-based composites and localized delivery of antimicrobial agents when the services are performed by a participating general dentist. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. The Plan had network providers available who could have provided 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. Based on this information, we decided that the Plan's rules for coverage of the comprehensive periodontal exam, resin-based composites and localized delivery of antimicrobial agents have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), resin-based composite - three surfaces, posterior (D2393) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided November 19, 2020.

Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 clinical information provided supports the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the medical records did not support the need for an intensive rehabilitation program requiring at least 3 hours per day for 5 days per week, goals for measurable improvement, close physician involvement, skilled nursing care, physical therapy, occupational therapy or orthotic/prosthetic training.

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 peripheral artery disease and had right above the knee amputation. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.

You asked the Plan to pre-approve the continuation of care with an OON provider. You say that you have issues with your retina. You say that your eyes are red, your retina is falling off, your vision is blurry, and you cannot see. You say that you need to see the specialist who has been treating you and to get injections. The Plan denied your request. The Plan says the enrollee can get medically needed care from a doctor that is in the network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 continuation of care with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee has type 2 diabetes mellitus and proliferative diabetic retinopathy with macular edema bilaterally, and branch retinal vein occlusion of the left eye with macular edema. The enrollee has been seeing an OON retinal ophthalmologist, and he has been receiving intravitreal injections of Avastin (Bevacizumab). There is nothing unique about this enrollee's condition that would make it medically necessary for him to continue care with the out of network provider. The plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical standards of care required for treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care can safely be transitioned to an in-network specialist at this time. 

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 continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on December 18, 2020, to December 22, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are retired, and you do not have to the money for this. 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 $492 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $492 copayment per day for days 1-4. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,968 ($492 x 4 days = $1,968). An inpatient hospital stay falls 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 copayment for an inpatient hospital stay provided by a participating provider on December 18, 2020, to December 22, 2020.
This appeal only addresses an inpatient stay. Please contact the Plan for additional service appeals.