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

We decided that the Plan does not have to pre-approvethe office visits to be provided by a non-contracted provider.You asked the Plan to pre-approvethe office visits. You say that the services are necessary to give the enrollee best quality of life.The Plan denied your request. The Plan says there are in-network doctors who can provide the care you need.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe office visits to be provided by a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of a continuous positive airway pressure device (CPAP).You asked the Plan to pre-approvecontinued CPAP use. You say that this is medically necessary.The Plan deniedyour request. The Plan says that the medical information submitted indicates that you have used your CPAP machine in the prescribed manner.The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.We looked at the file and Medicare rules. The compliance report included with the file indicates you did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP use have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of a continuous positive airway pressure device (CPAP).
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 was admitted to the acute care hospital with infection in the left foot. Surgical debridement was performed on February 5, 2021. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXifaxan.You asked the Plan to pre-approveXifaxan. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the requested drug is not a 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-approveXifaxan.Benefits for Xifaxanmay be available under Medicare Part D.Contactthe 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 evaluation and management services (99214-25) provided on January 29, 2020.
You asked the Plan to pay for the evaluation and management services. You say that there are no bundling issues and modifier 25 is correctly present. The Plan denied your request. The Plan says the benefit for the evaluation and management services is included in the payment and allowance for the other procedure that was already adjudicate and separately billed. The Plan says that these two procedures are bundled and are considered components of the same procedure. The Plan says that separate payment is not allowed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that physicians shall not unbundle services that are integral to a more comprehensive procedure. We asked our coding specialist 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 evaluation and management services. Our coding specialist reviewer says that the criteria for coverage have not been met. Our coding specialist reviewer found procedure 31575 (Laryngoscopy, flexible; diagnostic) was billed on the same date of service by the same physician/practice as CPT 99214. These two codes are bundled. However, per NCCI a modifier can be used to unbundle the two codes, providing the medical documentation in the enrollee's medical records supports doing so. In this case, the provided documentation does not include sufficient documentation to support billing of CPT 99214-25, therefore this service cannot be verified.
We looked at this coding specialist's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the evaluation and management services have not been met. Therefore, we decided that the Plan does not have to pay for evaluation and management services (99214-25) provided on January 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee has received more than two (2) months of rehab services with minimal improvement and appears to be at their new baseline functional status. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. Their physical function is at or near the enrollee's new baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary.
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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 21, 2020, by an out of network provider.You asked the Plan to pay foran office visit, a removal of tissue from finger or toe nails, and a removal of skin growths. You say that due to a misconception the provider's front desk secretary did not obtain prior authorization.The Plan denied your request. The Plan says rules for payment 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 forthe medical services provided on September 21, 2020, by an out of network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNeupro.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says self-administered drugs are not covered.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-approveNeupro.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 reviewer says that the requested IRF care is not considered medicallyreasonable 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 surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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-approveacute IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high frequency chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea high frequency chest wall oscillation system to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide this item. Therefore, coverage criteria has 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issuein this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on September 25,
2020.
You asked the Plan to waive the copayment for the facility fee. You say that you should not have to pay this
because you were never informed of a facility fee. 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 $325
copayment for each Medicare-covered non-surgical visit in an in-network outpatient clinic. For this date of
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325
copayment for the facility fee.
You have been asked to pay a $133.58 copayment for the facility fee. The facility fee falls within the
"Outpatient hospital 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 copayment for the facility
fee provided on September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office outpatient visit (99211) provided on July 10, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that the service should be covered.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.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 forthe office outpatient visit (99211) provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of a Vertiflex device (22869, 22870).You asked the Plan to pre-approvethe insertion of a Vertiflex device. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device.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 insertion of a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of a Vertiflex device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Prolia injection provided on June 5, 2020.You asked the Plan to waive the coinsurance forthe Prolia injection. You say that you received a Prolia shot in the arm given by a nurse. You say you in previous years this was 100% covered. 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 20% coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer. You have been asked to pay $169.67 which is 20% of the allowed amount for the Prolia injection. The allowed amount is $848.34. ($848.34 x 20% = $169.67). The Prolia injection falls within the "Medicare Part B Prescription Drugs" 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 forthe Prolia injection provided on June 5, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on July 23, 2020 by an out of network provider.You asked the Plan to pay forthe physician services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe physician services provided on July 23, 2020 by an out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that having a CGM will help you determine when to eat. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forProgressive lens (V2781) and eye exam with refraction (S0621) provided on September 8, 2020.You asked the Plan to pay foreye exam and lens. You say that the service should be covered.The Plan denied your request. The Plan says maximum benefits have been exceeded.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. The Plan covers routine eye exams once a year and up to $375 towards eyeglasses and lenses once a year.We looked at the file and the Plan's rules. The Plan covers routine eye exams once a year and up to $375 towards eyeglasses and lenses once a year.Based on this information, we decided that the Plan's rules for coverage of eye exam and lens have not been met. Specifically, records indicated you already utilized your plan benefits for these services for the 2020 calendar year. This means the services are not covered.Therefore, we decided that the Plan does not have to pay forProgressive lens (V2781) and eye exam with refraction (S0621) provided on September 8, 2020.