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

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 15, 2021.You asked the Plan to pay for the chiropractic services. You say that you are confused that you had to pay an additional $55 for a medical exam, particularly because there was no medical exam, for a total of $75. Please reconsider your claim and/or get your money ($55) back from the provider.The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on May 9, 2020.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 Current Procedural Terminology (CPT) code 97110 GP KX (4 units) remains not supported and there is a more appropriate code to use.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 asked our coding 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 coding reviewer found the therapy visit was performed by a qualified healthcare provider, with credentials, DPT (Doctor of Physical Therapy), however, visit does not document time spent with each area treated.  Therefore, this service cannot be confirmed as performed.We looked at this coder'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 physical therapy services (CPT 97110) provided to the enrollee on May 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gralise tablets.

You asked the Plan to pre-approve Gralise tablets. You say that the enrollee needs this medication. The Plan denied your request. The Plan says self-administered drugs are not a Medicare covered 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 Gralise tablets.

Benefits for Gralise tablets 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on
September 25, 2020.

You asked the Plan to waive the copayment for ambulance transport. You say that this transportation was for
an X-Ray, but the enrollee did not have an appointment when he got to the facility. The Plan denied your
request. The Plan says the copayment amount the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $260 copayment for ambulance transport.

The enrollee has been asked to pay $260 copayment for ambulance transport. Ambulance transport falls within
the Ambulance 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
ambulance transportation provided on September 25, 2020.
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 LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have 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 there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) admission and care.

You asked the Plan to pre-approve SNF admission and care. You say that the service is medically necessary.
The Plan denied your request. The Plan says that the service is not medically necessary and reasonable.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF admission and care. Our reviewer
says that the service is medically necessary. Our physician reviewer found daily skilled services are required to
establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care
needs at this point, as a practical matter, cannot be provided 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 SNF admission and care have been met. Specifically, the enrollee does require
daily skilled nursing services that cannot be obtained at a lower level of care. The Plan must continue coverage
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve
skilled nursing facility (SNF) admission and care.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.

You asked the Plan to pre-approve Orencia. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 Orencia. Our reviewer says that this drug is not medically reasonable and reasonable. Our physician reviewer found the Plan requires a trial of Stelara before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on May 2, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. 
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on May 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on December 8, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit 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 first intraoral periapical x-ray (D0220) provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in his current condition at a skilled nursing facility.The Plan denied your request. The Plan says it is not medically necessary to transfer to a LTACH facility.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 medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist services provided on February 12, 2021.

You asked the Plan to waive the co-payment for the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an office visit provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan. The Plan says that this specialist visit is exceeds the global surgery days allotted for your surgical procedure provided on January 13, 2021.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for each Medicare-covered specialist visit.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on February 12, 2021. You have been asked to pay a $35 co-payment for the specialist services. The specialist services fall within the Physician/Practitioner services 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 co-payment for the specialist services provided on February 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from September 12, 2019 to September 16, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from September 12, 2019 to September 16, 2019.

Benefits for these services 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 pay for the office visit provided on September 15, 2020 by a non-network provider.

You asked the Plan to pay for these 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 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 office visit provided on September 15, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve semi-electric hospital bed. You say that the enrollee needs this equipment to elevate and help breathing while resting.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not have a need for frequent and immediate changes in body position.

The Plan follows Medicare rules. Medicare rules state that a semi-electric hospital bed may be covered if the enrollee meets the criteria for a fixed height hospital bed and also requires frequent and/or immediate needs for a change in body position.

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 semi-electric hospital bed. Our reviewer says that the enrollee does not meet the Medicare criteria for a semi-electric hospital bed. Our physician reviewer found the enrollee has congestive heart failure and chronic obstructive pulmonary disease and requires the head of the bed to be at 35 to 40 degrees. However, the medical records do not indicate that the enrollee requires frequent or immediate changes in body position.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and knee orthosis with suspension
sleeve rendered on October 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any DMEPOS item to a beneficiary.

We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for the lumbar-sacral orthosis and knee orthosis with suspension
sleeve rendered on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and imaging services provided on November
2, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services
were reprocessed as in-network.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Providers must report services with the appropriate CPT code. The
file shows that a $35 copay for the imaging services. The services fall within the outpatient diagnostic tests
benefit category. This means that the enrollee was 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 when they enrolled in the Plan.
Therefore, we decided that the Plan does not have to further pay for the imaging services provided on
November 2, 2020.

The file shows that evaluation and management services were provided in conjunction with the imaging
services. These services were integral to accomplishing the provided services and are considered bundled.
Therefore, we decided that the Plan does not have to pay for the office visit provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says genicular nerve blocks are considered investigational for the treatment of chronic knee pain.

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 the requested services. Our physician reviewer found that the enrollee has left knee pain. She is taking Oxycodone/Acetaminophen, Gabapentin, Diclofenac gel and Lidocaine patches for pain. She has had physical therapy and is doing a home exercise program. The requested service is an experimental/ investigational procedure. Therefore, the request is deemed not medically necessary or reasonable.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitting of spectacles (92340) provided on January 19, 2021.

You asked the Plan to pay for fitting of spectacles. You say that you want the Plan to pay for the service. The
Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of fitting of spectacles have not been met. Specifically, the service at issue is not a covered benefit.
Therefore, we decided that the Plan does not have to pay for fitting of spectacles (92340) provided on January
19, 2021.