Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules.The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for fluid overload in the setting of heart disease and end-stage renal disease. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care,there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-ray (D0220), and protective restoration (D2940) provided from August 30, 2019 to September 10, 2019.You asked the Plan to pay forperiapical x-ray, and protective restoration. The Plan denied your request. The Plan says periapical x-rays are not listed as a covered service. The Plan also says that protective restoration in not listed as a covered serviceeither.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 periapical x-ray, and protective restoration are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periapical x-ray (D0220), and protective restoration (D2940) provided from August 30, 2019 to September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee still has weakness from the stroke.The Plan denied your request. The Plan says the enrollee does not require an intensive team of providers for care.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 physician reviewer found that the enrollee's current level of functions is moderate to maximal assist for mobility and activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that his medical status requires the intensity of an IRF stay with close physician or nursing supervision. Theenrollee may benefit and participate in additional physical and occupational therapy, but the documentation does not support that he requires this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to payforCPT codes J0897 and 96372 provided on August 20, 2019.You asked the Plan to pay forCPT codes J0897 and 96372. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the medical records provided do not support the billing of CPT codes J0897 and 96372.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 codes J0897 is Injection, denosumab, 1 mg and 96372 is Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.We find that CPT codes J0897 and 96372 are notsupported in the medical record. Specifically, the medical records provided did not include documentation of a detailed administration record for the injection, denosumab, 1 mg, and the medical records provided did not include documentation of a detailed administration record for the therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular. Based on this information, we decided that Medicare rules for coverage of CPT codes J0897 and 96372 have not been met as the services provided cannot be verified.Therefore, we decided that the Plan does not have to pay forCPT codes J0897 and 96372 provided on August 20, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided on August 10, 2019.
You asked the Plan to pay for a one-month supply allowance (K0553). You say that you are billing according to Medicare guidelines. The Plan denied your request. The Plan says that that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules state that a supplier does not have to deliver supplies used with a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month following the DOS on the claim. No more than 1 unit of service (UOS) for code K0553 per month is billable at a time. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity of BGM testing supplies at a time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a one-month supply allowance for therapeutic continuous glucose monitor have been met. Specifically, the supplies in this case were delivered in a 90-day supply for K0553, which the Proof of Delivery supports. The supplier is only billing one unit of K0553 at a time for supplies that are sufficient for one full month following the DOS on the claim. The supplier in this case is billing in accordance to Medicare rules for continuous glucose monitoring supplies. Therefore, we decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prolonged evaluation and management services provided on September 23, 2019 by out of network provider.You asked the Plan to pay forthe prolonged evaluation and management services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe prolonged evaluation and management services provided on September 23, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pontics(D6240) for teeth # 12 and 14 provided on March 8, 2019.You asked the Plan to pay forthe pontics. You say that the website indicates that the services you received on March 8, 2019 are covered up to $500.The Plan denied your request. The Plansays pontics are 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 pontics are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe pontics (D6240) for teeth # 12 and 14 provided on March 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 17, 2019 by out of network provider, "the provider".You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.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 forthe medical services provided on September 17, 2019 by out of network provider, "the provider".
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Aranesp injections.You asked the Planto pre-approvethe Aranesp. You say that you are not able to order this medication from the specialty pharmacy.The Plandenied your request. The Plansaysyou can order this medication from the mail order pharmacy and this is the required ESA drug.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 the Aranesp. Our reviewer says that the requested Aranesp is not considered medically reasonable and necessary based on step therapy requirements. Our physician reviewer found the enrollee is a 77-year-old woman with a diagnosis of Chronic kidney disease, stage 3 (moderate) with Anemia. The enrollee has not failed the required step therapy drug. The documentation does not support that Retacrit would likely be less effective, and/or would likelyhave adverse effects for the enrollee in this case.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 Aranesp have not been met.Therefore, we decided that the Plandoes not haveto pre-approveAranesp injections
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is too much to handle at a skilled nursing facility.The Plan denied your request. The Plan says the enrollee's needs can be met in the current inpatient hospital.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 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 he 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe diagnostic mammogram and the ultrasound provided on October 7, 2019.You asked the Plan to waive the copayments forthe diagnostic mammogram and ultrasound. You say that in the seven years since your original breast cancer diagnosis, you have not had to pay a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasounds). You have been asked to pay a $40 copayment for the diagnosticmammogram and a $40 copayment for the ultrasound. The diagnostic mammogram and ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 copayments forthe diagnostic mammogram and the ultrasound provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a battery backup for a CPAP.You asked the Planto pre-approvethe backup. You say that this is medically necessary.The Plandenied your request. The Plansaysthe request received does not have a medical order and/or a medical necessity certification that justifies the requested service.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medicallynecessary 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 the backup. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a battery backup for the enrollee's CPAP device is considered not medically necessary. Medicare does not cover such a device for CPAP. There is no medical order or documented justification for the device. Absence of electrical power in the home would also prevent recharging of the battery, rendering it ineffective.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 backup have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea battery backup for a CPAP.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe treatment of metatarsal fracture (28470) provided on September 19, 2019.You asked the Plan to waive the deductible forpodiatry services. You say that you do not feel you received sufficient treatment to warrant this charge.The Plan denied your request. The Plan says this service processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible. The Plan contract also says that the deductible applies to podiatry services.The service you asked the Plan to waive the deductible for is a podiatry service. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies to podiatry services. This cost sharing is a contractual obligation that had not been met at the time podiatry services was received on September 19, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe treatment of metatarsal fracture (28470) provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided from June 15, 2019 to June 17, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the Plan's denial.The Plan denied your request. The Plan says the member's primary insuranceis effective May 12, 2019 through July 20, 2019. Itis the provider's responsibility to directly bill the Primary Group Health Plan or any liability insurance before submitting the claim to the plan for payment. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submita bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan hasdirectedyour organizationto send the billto the primary insurer for payment. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided June 15, 2019 to June 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional intraoral x-rays (D0230), the resin based composite (D2330) for teeth # 6 and 27, and the resin based composites (D2391) for teeth # 2, 4, 5, 12, 18, and 29 provided on November 29, 2018.You asked the Plan to pay forthe additional intraoral x-ray, and the fillings for teeth # 2, 4, 5, 12, 18, 29, 6, and 27. You say that you were advised you needed to have x-rays in order to have a cleaning and they would be covered by insurance. You say that the x-ray showed you had a large cavity. You also say that you were not aware of how many fillings were covered, nor how many the provider filled at the office visit.The Plan denied your request. The Plan says the benefit limits havebeen exceeded. The Plan says that 1 intraoral x-ray is covered per calendar year. The Plan also says that 1 extraction every 3 years is 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.Though the Plan offers a dental benefit in excess of Medicare coverage and intraoral x-rays, and fillings are covered services, the frequency limits have been exceeded. The record shows that the Plan paid for 1 intraoral x-ray, and 1 extraction for date of service November 29, 2018.Therefore, we decided that the Plan does not have to pay forthe additional intraoral x-rays (D0230), the resin based composite (D2330) for teeth # 6 and 27, and the resin based composites (D2391) for teeth # 2, 4, 5, 12, 18, and 29 provided on November 29, 2018.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it ismedically 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.