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

We decided that the Plan does not have to pay for the home visit (99347) and the nail debridement (11721) rendered by the out-of-network (OON) provider on January 28, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at 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 for the home visit (99347) and the nail debridement (11721) rendered by the out-of-network (OON) provider on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cortisone injection procedure you had at an outpatient hospital clinic on March 25, 2021.
You asked the Plan to waive the copayment for the cortisone injection procedure at an outpatient hospital clinic. You say that you did not know that this would be billed as an outpatient hospital visit. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it confirmed that these services were not performed in the office of your primary care physician.
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 surgery and other services at an outpatient hospital facility. You have been asked to pay a $325 copayment for the cortisone injection procedure at an outpatient hospital clinic. The cortisone injection procedure at an outpatient hospital clinic falls within the surgery and other services at an outpatient hospital facility 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 cortisone injection procedure you had at an outpatient hospital clinic on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the claim and medical records were not submitted with a valid physician order.
The Plan must follow Medicare rules. The rules state that claims cannot be paid without submission of an
appropriate physician order.
The record does not contain a valid physician order. 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 lab services provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs rendered on March 11, 2021.
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 claim was not billed with the required NDC number.
The Plan must follow Medicare rules. The rules say that all drugs, including Prodrugs, are reported to DME
MACs by National Drug Code (NDC).
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required NDC
number. 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 drugs rendered on March 11, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field examination, unilateral or bilateral, with interpretation and report; extended examination (92083) provided April 9, 2021, and the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (99204) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided April 14, 2021.
You asked the Plan to waive the copayment for the visual field test, medical eye exam and imaging of the optic nerve. You say that you normally have these service on one day but were required to have them on 2 separate
days this year and do not think it is fair to be charged two separate copayments. The Plan denied your request.
The Plan says the copayments have been applied correctly to each service.
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
copayment for each Medicare-covered eye exam for the diagnosis and treatment of diseases and injuries of the
eye.
You have been asked to pay a total of $40 ($20 copayment x 2 separate Medicare-covered eye exams and
services = $40) for the vision services. These services fall 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 the visual field examination, unilateral or bilateral, with
interpretation and report; extended examination (92083) provided April 9, 2021, and the ophthalmological
services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment
program; comprehensive, established patient, 1 or more visits (99204) and scanning computerized ophthalmic
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
(92133) provided April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Zoom online yoga classes requested on June 1, 2021.

You asked the Plan to pay for the classes. You say that because of the pandemic, your usual yoga class switched to a Zoom format. The Plan denied your request. The Plan says this is not a covered benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only in a qualified fitness program under a full service health club or a fitness studio. 

The Plan's rules for coverage of gym benefits have not been met because the plan does not cover online fitness classes. Therefore, we decided that the Plan does not have to pay for Zoom online yoga classes requested on June 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from April 1, 2021, to April 28, 2021.
You asked the Plan to waive the copayments for the PT services. You say that you were told that PT was covered and unlimited. You said that you were never told there would be a copayment. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per day for outpatient rehabilitation services, including PT. You have been asked to pay a $35 copayment per day for the PT services. 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 copayments for physical therapy (PT) services you received from April 1, 2021, to April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).

You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee has tried and failed any of the Plan's preferred drugs.

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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not approved as step criteria have not been met. Our physician reviewer found the enrollee has not trialed one viscosupplemental treatment such as Synvisc/Synvisc-One, Orthovisc, or Monovisc. Step therapy, as outlined by the Plan, requires that one of these be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 25, 2021. You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not ordered or approved by the enrollee's treating physician. The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The Plan has attested that the enrollee's treating physician denied ordering this testing. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified periodontal procedure, by report (D4999) provided November 10, 2020.

You asked the Plan to pay for the unspecified periodontal procedure. You say that the dental office said your services would be covered. The Plan denied your request. The Plan says the claims from this date of service have been reprocessed, however this service is not covered under your benefits. The Plan further says that your additional concerns with the dental office are being investigated separately.

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 unspecified periodontal procedure, by report (D4999) provided November 10, 2020.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the patient has a past medical history of T8 spinal cord injury, traumatic brain injury and neurogenic bladder. He is living at home with a caregiver and having increasing trouble with transfers and self-care. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Unfavorable

We decided that the Plan does not have to pre-approve Acthar (J0800).
You asked the Plan to pre-approve Acthar. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not approved by the Food and Drug Administration (FDA) for your diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. The rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of Acthar have not been met. Specifically, the submitted documentation does not include any clinical information. There is insufficient information to determine if the requested drug is medically necessary. Please note, the Plan has indicated that requests for this documentation have been submitted, but medical records have not been received Therefore, we decided that the Plan does not have to pre-approve Acthar (J0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery provided on November 12, 2020.

You asked the Plan to pay for repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm (13121) and repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (13122). You say that the surgery was medically necessary. The Plan denied your request. The Plan says despite multiple outreached the provider has not submitted any clinical records to support the medical necessity of the service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. There is no imaging documentation or physical exam notes in the case file. Based on this information, we decided that Medicare rules for coverage of repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm (13121) and repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (13122) have not been met. Therefore, we decided that the Plan does not have to pay for the surgery provided on November 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 9, 2021.

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 billed place of services is not supported.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 15 for a mobile unit; however, the file shows that the services were performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the testing services rendered on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supplemental Benefits for the Chronically Ill.
You asked the Plan to pre-approve Supplemental Benefits for the Chronically Ill. You say that you would like reconsideration for the Supplemental Benefits for the Chronically Ill. The Plan denied your request. The Plan says the member does not have an eligible medical condition, high risk of hospitalization or require intensive care coordination.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supplemental Benefits for the Chronically Ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve Supplemental Benefits for the Chronically Ill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 18, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says while a portion of this claim was paid, Medicare does not provide coverage for services not related to manual manipulation of the spine.
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 chiropractic services provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 25, 2021 to February 28, 2021.
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 procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of critical care services for 30-74 minutes spent on the enrollee for the billed dates of service. 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 critical care services rendered on February 25, 2021 to February 28, 2021.
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 the enrollee is receiving the appropriate care at this time.
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 that there is no documentation provided indicating medical necessity for admission to a 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 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460), the consultation (D9310), and
the unspecified preventive service (D1999) provided on March 26, 2021.

You asked the Plan to pay for the dental services. You say that you should have been consulted prior to the
procedures being done. You say that you are not paying for these charges. You also say that the services should
be covered. The Plan denied your request. The Plan says pulp vitality test is not listed as a covered service. The
Plan says that consultation is not listed as a covered service. The Plan says that unspecified preventive service
is not listed as a covered service either.

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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp
vitality test (D0460), the consultation (D9310), and the unspecified preventive service (D1999) provided on
March 26, 2021.