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

We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99337)
provided on March 2, 2021, by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you have enclosed the supporting
medical records to prove the need for the services rendered to be paid to the provider of the service. The Plan
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers
require prior authorization before services being rendered.
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 established patient domiciliary or rest home
visit (99337) provided on March 2, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.
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 double vision and tremors. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bridge provided on December 28, 2019.
You asked the Plan to pay for the bridge. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your dental plan.
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 bridge provided on December 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography services (CPT 93306) provided to the enrollee on February 22, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says based on the ICD-10-CM, a secondary-only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
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 93306 is "ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY." 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records.
Our physician reviewer found the ICD-10 code was incorrectly billed in this case. R65.21 is a secondary code,
and is unacceptable as a principal diagnosis. According to ICD-10-CM guidelines this code should not to be
used as a principal diagnosis code when a related definitive diagnosis has been established. Therefore, this
service would not be covered.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for echocardiography services (CPT 93306) provided to the enrollee on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on December 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that prior authorization was not obtained because the enrollee was seen on short notice. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 office services provided on December 23, 2020 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 1, 2020 by an
out of network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit (99214) provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings (G0156).

You asked the Plan to pre-approve the services of home health/hospice aide. The Plan denied your request. The Plan says this request is not medically necessary because the carrier's guidelines are not met given the information provided. The Plan also says that it is noted that the home health aide service is a complex level of home care and your needs can be met with less complex services.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 services of home health/hospice aide. Our reviewer says that the daily presence of a nurse is not shown to be medically necessary or reasonable. Our physician reviewer found you have been receiving home health registered nursing services on a daily basis for medication management.

Our reviewer found that there appears to have been no significant changes to your medication regimen. Our physician reviewer also found that while you may be forgetful, it is unclear why your medications cannot be set up on a weekly basis and overseen by your HHA or nearby family. 

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 services of home health/hospice aide have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient psychiatric care provided on January 3 to January 18, 2021.

You asked the Plan to waive the copayment for inpatient psychiatric care. You say that you were not aware of any copayments under your Plan benefit. The Plan denied your request. The Plan says the correct copayment was 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 $325 copayment for each day of days 1 to 5 each time you are admitted for Medicare-covered hospital care. 

You have been asked to pay $1,625, or a $325 copayment for each day of days 1 to 5, for inpatient psychiatric care. Inpatient psychiatric care falls within the "Inpatient mental health 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 inpatient psychiatric care provided on January 3 to January 18, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance for an injection provided by a participating provider on February 19, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says that the correct coinsurance has been applied.
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 has failed to include all the necessary information needed to determine a decision. Therefore, we decided that the Plan has to waive the coinsurance for an injection provided by a participating provider on February 19, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81265, 81266) provided on February 16, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not emergent or pre-authorized. There were 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 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 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 lab services (81265, 81266) provided on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab for the enrollee.

You asked the Plan to pre-approve the drug. You say that the step therapy drugs are not FDA-approved for the
enrollee's diagnosis. The Plan denied your request. The Plan says treatment with a biosimilar is recommended.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Ruxience or Riabni. The documentation does not support that Ruxience and/or Riabni would likely be less effective, and/or would likely have 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a physical medicine and rehabilitation specialist on March 11, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you do not believe you should have to pay this copayment since this visit was mandated by your insurance company. 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). Your contract with the Plan clearly says that you must pay a $45 copayment for visits with a specialist. You have been asked to pay a $45 copayment for the specialist visit. This copayment applies regardless of the reason for the visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had with a physical medicine and rehabilitation specialist on March 11, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the thorax.

You asked the Plan to pre-approve a CT scan of the thorax. You say that the requested CT scan of the thorax is medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the thorax is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the thorax. Our reviewer says that the requested CT scan of the thorax is medically necessary. Our physician reviewer found a repeat CT scan of the chest is reasonable and medically necessary. This enrollee has progressive interstitial lung disease, with a previous high-resolution chest CT in 2019 showing progression. A CT of the chest was done in May 2021 in Geneva, but reportedly, this was not done as a high-resolution scan. This makes it difficult to compare with previous imaging and makes it more difficult to establish the category of ILD (NSIP vs UIP). The decision of whether to treat the enrollee with antifibrotic medication hinges on this interpretation. For this reason, the repeat CT is needed, with a high-resolution protocol. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the thorax have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the thorax.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee x-ray (73564) x-ray of upper extremities (73140) shoulder x-ray (73030) provided June 1, 2020 to September 15, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you were charged $100 for three visits for x-rays. You also paid the $40 copay three times for the office visits. The office is at an office facility building not a hospital. The Plan denied your request. The Plan says the correct copayment was applied per the Evidence of Coverage.
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 $100 copayment for diagnostic procedures and tests in an outpatient hospital.
You have been asked to pay $259.34 ($100 + $79.64 + $79.64) for the diagnostic services. Since the allowed amount for the services provided on June 1, 2020 and September 15, 2020 were $79.67, which is less than the copay amount of $100, you are responsible for the lesser amount. The plan has confirmed with the provider that you will receive a refund. The diagnostic services 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 copayment for the knee x-ray (73564) x-ray of upper extremities (73140) shoulder x-ray (73030) provided June 1, 2020 to September 15, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device (E0601) provided on March 3, 2021, by an
out of network provider.

You asked the Plan to pay for a CPAP. You say that the requested item is a medical necessity for the enrollee.
The Plan denied your request. The Plan says rules for out of network care have not been met.

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 a CPAP device (E0601) provided on March 3, 2021, by an out of network provider.