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

We decided that the Plan does not have to pay for inpatient hospital care provided from December 27, 2019, to December 30, 2019.

You asked the Plan to pay for inpatient hospital care. You say that inpatient admission was medically necessary. The Plan denied your request. The Plan says all inpatient care was unauthorized post-stabilization care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 inpatient hospital care. Our reviewer says that inpatient hospital care was not medically necessary in this case. Our physician reviewer found the documentation indicates that as of 5:45 p.m. on December 27, 2019, the enrollee was stable for ambulance transport with monitoring to a Plan facility. He had a history of hepatic encephalopathy and was seen, "multiple times," for this condition. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from December 27, 2019, to December 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS emergency ambulance service (A0427) and ground mileage (A0425).

You asked the Plan to pay for the ambulance services. You say that you are requesting review of the below claims and reprocess towards the payment for your providers. The Plan denied your request. The Plan says the explanation of benefits (EOB) from the primary insurance carrier is needed to process the claim.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, there is another insurance as primary and the Plan is secondary. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for ALS emergency ambulance service (A0427) and ground mileage (A0425).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) and somatosensory testing (95938) provided on June 1, 2020.

You asked the Plan to pay for needle electromyography and somatosensory testing. You say that this was billed with the correct POS. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. If the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 

We looked at the file and Medicare rules. The services at issue were billed with POS 15, but the record shows that the mobile unit was serving an entity for which another POS code already exists. Based on this information, we decided that Medicare rules for coverage of needle electromyography and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) and somatosensory testing (95938) provided on June 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room care services.

You asked the Plan to waive the copayment for the emergency room services. You say that you disagree with the copayment assessed. The Plan denied your request. The Plan says the correct cost share amount applied to the claim.

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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for the emergency room services. These services fall within the emergency 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 the emergency room care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950).

You asked the Plan to pre-approve this should be paid for.. You say that this is medically necessary. The Plan denied your request. The Plan says this service is not listed as a covered 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. Therefore, we decided that the Plan does not have to pre-approve dental services (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6104, D6010, D6057, D6058, D4266, D2740, D5225) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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. Therefore, we decided that the Plan does not have to pre-approve dental services (D6104, D6010, D6057, D6058, D4266, D2740, D5225) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).

You asked the Plan to pre-approve the maxillary partial denture. You say that you do not want a maxillary partial denture with a metal base. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.

You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a facility beyond the last covered date. The enrollee is able to perform G tube care and is amenable to enteral nutrition at home. The enrollee does not have complex wound care or other skilled needs that requires a facility stay. The enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a facility beyond the last covered date.

Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care.

You asked the Plan to waive the copayment for vision care. You say that you feel that the charges are unfair. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for vision care.

You have been asked to pay a $35 copayment for vision care. Vision care falls within the vision 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 vision care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic sinus surgery.

You asked the Plan to pre-approve endoscopy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there have been no significant abnormal Computed Tomography (CT) findings and no documentation of failure to respond to maximal medical treatment.

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 endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has undergone multiple sinus surgeries. A Computed Tomography (CT) scan demonstrated no findings to indicate acute or chronic sinusitis. Prior nasal endoscopy in September 2020 revealed a small amount of yellow mucous on the left maxillary antrostomy mucosa that was suctioned out but otherwise all tissues looked healthy and no signs of sinusitis or polyposis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic sinus surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen inj.

You asked the Plan to pre-approve Epogen. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the medical benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration and billed to the enrollee. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Epogen inj.

Benefits for Epogen 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says supplies are available from the preferred brand.

The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers for DME and supplies. 

We looked at the file and Medicare rules. The services at issue are test strips from a non-preferred provider. The Plan has approved coverage of these strips through April 1, 2021. Further strips beyond this date can be provided by the preferred provider(s). Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy.

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.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Magnetic resonance angiography (MRA) scan of neck blood vessels before and after contrast.

You asked the Plan to waive the copayment for the MRA. You say that you want the copayment waived. The Plan denied your request. The Plan says the correct cost-share applied to the claim.

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 $200 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $200 copayment for the MRA. The MRA falls 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 Magnetic resonance angiography (MRA) scan of neck blood vessels before and after contrast.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department visit (99285).

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because you billed correctly based on the Plan's guidelines. The Plan denied your request. The Plan says that the claim billed was not appropriate for the diagnosis billed.

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. Specifically, the Plan has not included any information as to why this diagnosis code is inappropriate for the service billed. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pay for an emergency department visit (99285).

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service provided on February 6, 2020.

You asked the Plan to pay for ambulance service. You say that the enrollee revoked hospice due to seeking aggressive treatment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance service provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 20, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. 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 for physician's services provided on August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary.

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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer device 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture and a mandibular partial denture.

You asked the Plan to pay for the partial dentures. You say that you lost your previous partials. The Plan denied your request. The Plan says these services exceed the benefit allowance. The Plan also says that these services are allowed once per 5 calendar 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dentures or fixed prosthetics/partials are covered once every 5 years. The record shows that you received a maxillary partial denture and a mandibular partial denture on October 17, 2020, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture and a mandibular partial denture.