Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue, and there are in-network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the item is medically necessary. The Plan denied your
request. The Plan says the item is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 preapprove Prolia. Our reviewer says that the item is
not medically necessary. Our physician reviewer found there is no documentation that Prolia is FDA-approved
for the enrollee's diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Specifically, the drug requested in not FDA approved
for the enrollee's diagnosis. This means the drug is not medically necessary or reasonable and cannot be
covered. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, it was not reasonable to suspect the enrollee's inpatient stay would span over two midnights. This means acute inpatient hospital care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screening test provided on August 20, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. There are insufficient records to show the results of the testing would be used in the management of a specific medical problem for the enrollee. The test at issue in this appeal, the testing services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardio screening test provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF services. The Plan denied your
request. The Plan says you can safely receive the services needed in other settings.
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 there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon services are not payable for these procedures.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 24066 and 23931. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage
criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the enrollee has an appointment to receive Prolia on June 30, 2021. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on
November 12, 2020.

You asked the Plan to waive the copayment for office visit. You say that this was an annual checkup, and you
were advised that there was no copayment due. The Plan denied your request. The Plan says the copayment
amount you are being charged is correct.

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 $30
copayment for primary care visit. This visit addressed a non-routine diagnosis; therefore, an office visit with
copayment was billed in addition to the preventive physical exam which you have not been asked to pay a
copayment for.

You have been asked to pay $30 copayment for office visit. Office visit falls within the Physician/Practitioner
Services, Including Doctor's Office Visits 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 a primary care office visit provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wigs provided on October 11, 2020.

You asked the Plan to pay for the wigs. You say that your doctor gave you a prescription for the wigs and you thought they would be covered. The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wigs may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wigs provided on October 11, 2020.

Your complaint about the Plan providing the incorrect information 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic services provided on September 28, 2020.

You asked the Plan to pay for the services provided. You say that the original claim had a subluxation code as the primary diagnosis. The Plan denied your request. The Plan says that the provider has not met the diagnosis relationship.

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.

We looked at the file and the rules. The case file does not include a claim for the billed services at issue. The Plan did not provide any documentation to show the services were not billed according to Medicare guidelines. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the chiropractic services provided on September 28, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall, anemia and pneumonia. The enrollee's medical conditions are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telehealth physician services (99214-95) provided on January 27,
2021.

You asked the Plan to pay for the telehealth physician services. You say that you have had this same telehealth
service appointment and it has always been covered by the Plan and you are unsure why this telehealth visit
was not covered. The Plan denied your request. The Plan says that the services are not covered.

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 telehealth physician visit was provided by a contract provider. The file does not show that the Plan
provided notice that the telehealth physician services would not be covered. Under Medicare rules, this means
the telehealth physician services is considered approved by the Plan. Furthermore, the Plan made no attempt to
obtain medical records to determine if the contracted provider billed the services correctly. Therefore, we
decided that the Plan has to pay for the telehealth physician services (99214-95) provided on January 27, 2021.

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: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on February 8, 2021.

You asked the Plan to waive the copayment for the magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material (72148). You say that you were told there would not be a copayment. The Plan denied your request. The Plan says you were charged this copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $180 copayment for Outpatient Diagnostic Tests, Advanced Imaging Services. 

The enrollee has been asked to pay a $180 copayment for the MRI (72148). The MRI falls within the Outpatient Diagnostic Tests, Advanced Imaging Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on February 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on June 5, 2020.
You asked the Plan to pay for the therapeutic procedure services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation submitted indicates that the services were performed by a physical therapist in the home setting.
There is a more appropriate code to be billed for these services. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on June 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement (11042) provided on February 12, 2021.

You asked the Plan to pay for debridement. You say that multiple debridement procedures are billable. The Plan denied your request. The Plan says the billed units exceed MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 11042 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of debridement have not been met. Therefore, we decided that the Plan does not have to pay for debridement (11042) provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on October 8, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the testing was not approved by the ordering provider.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. We find that the testing at issue is not supported. The documentation in the case file shows that the ordering physician did not authorize or order the testing. All diagnostic tests must be ordered by the physician who is treating the enrollee for a specific medical problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medial Branch Block (64494).
You asked the Plan to pre-approve the Medial Branch Block. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when 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 the Medial Branch Block. Our reviewer
says that the requested procedure is not medically necessary. Our physician reviewer found a second set of Medial Branch Blocks can only be approved if the first set provides greater than 80% pain relief. Since the effectiveness of the first set is not documented in the record, a second set is not supported 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 Medial Branch Block have not been met. Therefore, we decided that the Plan does not have to pre-approve a Medial Branch Block (64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
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 the physician services provided on March 18, 2021 by an out of network (OON) provider.