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

 
We decided that the Plan does not have to pay for discharge management (99239) services provided July 8, 
2020. 
 
You asked the Plan to pay for the discharge management services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services 
 
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 99239 is Hospital Discharge Day Management, more 
than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
30 minutes or more was spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the discharge management services have not been met. Therefore, we decided that the Plan does 
not have to pay for discharge management (99239) services provided July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral 
periapical x-ray provided on November 6, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You 
say that you believe these services should be covered. The Plan denied your request. The Plan says benefits for 
these services have been satisfied and the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on January 21, 
2020 and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have 
to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on November 6, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a 
participating provider on August 6, 2020, to August 31, 2020. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed 
amount is $105.33. The total amount you are being asked to pay is $21.06 ($105.33 x 20% = $21.06). The 
correct copayment has been applied to the medical supplies that were provided. Medical supplies fall within the 
durable medical equipment/in-network benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for medical supplies provided by a participating provider on August 6, 2020, to August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
December 1, 2020. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you changed dental providers and 
because you were a new patient, they provided this service. The Plan denied your request. The Plan says the 
service is a covered benefit, but you have exceeded the frequency limit of one every three years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of comprehensive oral evaluation have not been met. Specifically, the record shows that you had 
exceeded the frequency limit prior to this service on January 16, 2020. Therefore, we decided that the Plan does 
not have to pay for a comprehensive oral evaluation (D0150) provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee is not expected to be able to take part in 3 hours of therapy a day.

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 physician reviewer found that the enrollee was admitted to the acute hospital for respiratory failure and COVID 19 pneumonia. Her medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 skilled nursing facility is not properly equipped to rehabilitate the enrollee. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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. While the 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on September 29, 2020. 
 
You asked the Plan to pay for a back brace. You say that this should be covered. The Plan denied your request. 
The Plan says there is insufficient evidence that this was provided in connection to a valid telehealth visit.  
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) 
provided on September 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PT visits provided from June 8, 2016, to June 17, 2016, 
by an OON provider. 
 
You asked the Plan to pay for the PT visits. You say that you do not agree with the request of an over-payment 
from the Plan. The Plan denied your request. The Plan says the services were rendered by a non-network 
provider, and another non-network provider referred the enrollee for services. The Plan also says that the 
enrollee's network primary care physician did not refer for services. 
 
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 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 PT visits provided from June 8, 2016, to June 
17, 2016, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and 
prophylaxis provided on November 10, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
contacted the company two times to get a list of in-network providers. You also say that you would like these 
services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON 
provider and are not covered. The Plan also says that services performed by an OON provider are not covered 
because your plan does not have OON benefits. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. The record shows that there were no calls from you to 
the Plan requesting an in-network provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation, bitewing x-rays, and prophylaxis provided on November 10, 2020 by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare guidelines limit BRCA testing to once in a lifetime

The Plan must follow Medicare rules. The rules state that BRCA testing is covered once per lifetime. 

The file shows that BRCA 1 and 2 gene analysis testing was previously received in 2005. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA testing for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says there is no need for an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.

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 patient was admitted for a tibial plateau fracture after a fall. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 pre-approve Retacrit. Our reviewer says that the documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has kidney failure and anemia. Bone marrow biopsy results were normal. Most recent submitted labs were Hgb 10.3, Hct 31. Anemia related to chronic severe kidney disease is an FDA indication for Retacrit. Epoetin alfa is indicated in enrollees for the treatment of anemia due to chronic kidney disease, including patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion, Class IIa. Guidelines suggest treated with epoetin alfa for those with hgb consistently less than 11 g/dL. Therefore, the enrollee meets criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan has to pre-approve Retacrit.

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) and 
unspecified periodontal procedure (D4999) provided on December 4, 2020. 
 
You asked the Plan to pay for the periodontal services. You say that you did not realize these services were not 
covered and would not have had them done if you knew. The Plan denied your request. The Plan says these 
services are not covered by Medicare or by your Plan's mandatory supplemental dental benefit. 
 
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. The record indicates that you were not enrolled in the Plan's additional 
optional supplemental dental benefit at the time of these services. The mandatory supplemental dental benefit 
only includes certain routine, preventative services. Therefore, we decided that the Plan does not have to pay 
for the periodontal scaling and root planing (D4341) and unspecified periodontal procedure (D4999) provided 
on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0648) provided on September 10, 2020. 
 
You asked the Plan to pay for a back brace. You say that this is supported in the records. The Plan denied your 
request. The Plan says the submitted records do not document a face-to-face encounter. 
 
The Plan must follow Medicare rules. Medicare rules say that for DMEPOS items appearing on the Required 
Face-to-Face and Written Order Prior to Delivery List, the treating practitioner must document and 
communicate to the DMEPOS supplier that the treating practitioner has had a face-to-face encounter with the 
beneficiary within the 6 months preceding the date of the written order/prescription. The face-to-face encounter 
must be used for the purpose of gathering subjective and objective information associated with diagnosing, 
treating, or managing a clinical condition for which the DMEPOS is ordered.  
 
We looked at the file and Medicare rules. The submitted medical records do not document a valid face-to-face 
encounter. The records do not document both subjective and objective information. Based on this information, 
we decided that Medicare rules for coverage of a back brace have not been met. Therefore, we decided that the 
Plan does not have to pay for a back brace (L0648) provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) 
provided on August 18, 2020. 
 
You asked the Plan to pay for CGM supplies. You say that this should be covered. The Plan denied your 
request. The Plan says documentation supporting this claim has not been received. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Records supporting the supplies at issue have 
not been submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for continuous 
glucose monitor (CGM) supplies (K0553) provided on August 18, 2020.