Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99337) provided on April 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for domiciliary visit. You say that you provide medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 domiciliary visit (99337) provided on April 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Cemiplimab injection you received on
March 12, 2020.
You asked the Plan to waive the coinsurance for the Cemiplimab injection. You say that your insurance should
pay this in full. The Plan denied your request. The Plan says you were charged this coinsurance 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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Cemiplimab injection. The Cemiplimab injection falls
within the Medicare Part B drugs 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 coinsurance for
the Cemiplimab injection you received on March 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit and brief emotional or behavioral assessment (99336, 96127) provided on May 7, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the established patient assisted living visit and brief emotional or behavioral assessment. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 established patient assisted living visit and brief emotional or behavioral assessment (99336, 96127) provided on May 7, 2020, by an out of network (OON) 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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia. From a nursing perspective, the enrollee received oral, inhaled and ophthalmic medications. The enrollee had stable vital signs. She was said to be independent with functional mobility and required varying assist with activities of daily living.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a SNF 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: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 22, 2020 and
billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the documentation submitted did not support that the denied codes were performed with
blood sampling. Blood specimen collection is by venipuncture; however, the lab requisition states a urine
specimen was collected; therefore, the billed service cannot be verified. It is noted multiple attempts were made
to obtain additional information from the provider.
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, this claim cannot be paid based on
the type of specimen reported. Medicare rules for coverage of have not been met. Therefore, we decided that
the Plan does not have to pay for lab services provided to the enrollee on April 22, 2020 and billed under codes
80157, 80177, 80201, 80162, 80159 and 80173.
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 enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with
an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy
program.

The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for
functional improvement however, the documentation doesn't support that she would meet criteria for
admission to an acute inpatient rehabilitation facility. There is no indication that the member would require
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a
physician with at least 3 visits weekly to regain or maintain her functional status. The member is ambulating
up to 120 feet with a rolling walker. She could receive services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vehicle carrier platform for your scooter.
You asked the Plan to pre-approve a vehicle carrier platform. You say that you scooter is not portable and needs a special device to put it in the car. The Plan denied your request. The Plan says carrier platforms are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a vehicle carrier platform for your scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by a non-participating 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you feel safe with the provider, and he has 
done all the work in your mouth. The Plan denied your request. The Plan says the provider does not participate 
in your dental network. 
 
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.  
 
We looked at the file, and Medicare rules. The provider you requested does not participate in your dental 
network. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pre-approve dental services to be provided by a non-participating 
provider.
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 appears to be gradually improving and requires additional acute care services which can safely be 
performed at the current facility. It is not clear if weaning is possible with this enrollee based on the recent 
notes. The enrollee does not require services at the LTACH that are not already available at the current facility. 
Therefore, this request for LTACH services will be considered not medically 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 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: Partially Favorable

 
We decided that the Plan has to hold you harmless for the preventive procedure. We decided that the Plan does 
not have to pay for the intraoral periapical x-rays.  
 
You asked the Plan to pay for the preventive procedure, first intraoral periapical x-ray, and additional intraoral 
periapical x-ray. You say that the provider did not have time to completely clean your teeth, and took up your 
time taking unnecessary x-rays. The Plan says that participating providers are receiving a separate monthly 
stipend for the unspecified preventive procedure. The Plan also says that the benefits for the intraoral x-rays 
have been satisfied and the frequency limitation has been exceeded. 
 
We decided that the Plan has to hold you harmless for the preventive procedure.  
 
Medicare rules say that a contract provider is an agent of the Plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The file does not show that the Plan provided notice that the preventive procedure would not be covered. Under 
Medicare rules, this means the preventive procedure is considered approved by the Plan. The Plan also says 
that participating providers are receiving a separate monthly stipend for the unspecified preventive procedure. 
Therefore, we decided that the Plan has to hold you harmless for the preventive procedure.  
 
 
We also decided that the Plan does not have to pay for the intraoral periapical x-rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on February 
11, 2020, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the intraoral periapical x-rays. 
 
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. 
 
Your complaint about being provided with possibly unnecessary x-rays 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81173, 81201, 81121, and 81120) provided on January 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 laboratory services (81173, 81201, 81121, and 81120) provided on January 12, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says Procrit to be dispensed by the enrollee's pharmacy to self-administer is
not covered under the enrollee's Medicare Part B benefit. The Plan says this drug has been approved under the
enrollee's Part D benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Benefits for Procrit 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 29, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that your periodontal disease was under control so you switched to a plan with lower coverage. You say that your cleaning was denied. You say that you received a regular cleaning and not periodontal maintenance. You also say that there was no probing included in the cleaning that you had, which is what differentiates a regular cleaning from periodontal maintenance. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extractions (D7210 x 2) provided on June 23, 2020.
You asked the Plan to reimburse you for the dental services. You say that your dental coverage says that you can go out of network for dental services. You say that your tooth broke just after the shutdown. You also say that the services were approved before you went in. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that the provider is not permitted to send claims to Medicare or Medicare Advantage plans, except for emergency or urgent care services.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The record shows that a notification letter was sent on February 6, 2020 advising that the provider would no longer be participating with the Plan's Dental Medicare network. Therefore, we decided that the Plan does not have to reimburse you for the surgical extractions (D7210 x 2) provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 25, 2019
and billed under code 80162, 80159, and 80173.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the documentation submitted did not support that denied testing was performed with
blood sampling. Blood specimen collection is by venipuncture; however, Documentation submitted does not
indicate that a blood/serum specimen was collected in order to support the billed code. Therefore, the validity
and accuracy of the claim cannot be verified. Of note, the submitted blood/serum requisition did not contain the
billed test. It is noted multiple attempts were made to obtain additional information from the provider.
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 claim submitted cannot be paid
due to an issue with the specimen reported. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November
25, 2019 and billed under code 80162, 80159, and 80173.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opsumit.
You asked the Plan to pre-approve Opsumit. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Opsumit.
Benefits for Opsumit 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Allograft for spine surgery (20930).
You asked the Plan to pre-approve Allograft. You say that the enrollee would like to proceed with the surgery without further delay. This enrollee is stuck in a cycle of pain and activity limitations that adversely affect her quality of life. The Plan denied your request. The Plan says there is no evidence this type of graft is better than the others used in this type of surgery.
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 Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Allograft remains experimental for use in the posterolateral spine. More research is needed to show safety and efficacy. It should not be approved. The gold standard is iliac crest autograft. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Allograft for spine surgery (20930).