Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Denosumab injection and administration (J0897, 96401) provided on July 1, 2020.You asked the Plan to waive the coinsurance forthe Denosumab injection and administration. You say that you were never charged this coinsurance before and would like this claim reprocessed.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 Medicare Part B prescription drugs in addition to the office/outpatient member liability. You have been asked to pay a total cost share of $247.31 for the services provide. The Denosumab injection and administration 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 Denosumab injection and administration (J0897, 96401) provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea treadmill.You asked the Plan to pre-approvea treadmill. You say that this is necessary for your health.The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.The Plan covers all items that Medicare covers. Medicare rules state that exercise equipment is not covered because it is not primarily medical in nature. While exercise equipment may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea treadmill.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy services provided on August 12, 2020.You asked the Plan to waive the copayment forthe physical therapy services. You say that you were told that your insurance would pay for physical therapy services.The Plan denied your request. The Plan says the services are covered and you have been charged the copayment 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 for physical therapy. You have been asked to pay $35 for the physical therapy 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 inthe Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe physical therapy services provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea platelet-rich plasma injection.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show a covered indication.The Plan must follow Medicare rules. Medicare rules say that PRP is not currently covered. There is not enough evidence in the current medical literature to cover the requested injection. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea platelet-rich plasma injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) and the root canal (D3330) provided.

You asked the Plan to reimburse you for the dental services. You say that  The Plan denied your request. The Plan says the specified dental codes that are listed are covered at 100%. The Plan says that the dental codes that are not listed, but are medically necessary are covered at 50%. The Plan also says that the services you received are not listed , nor are they medically necessary.

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 reimburse you for the periapical x-ray (D0220) and the root canal (D3330) provided.
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 for the enrollee. 

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member could be evaluated and treated in a skilled nursing facility. 

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 medically reasonable and necessary based on Medicare guidelines. The complexity of the patient'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 abdominal pain and was treated for diabetic ketoacidosis. He developed left lower leg ischemia and had a left above the knee amputation. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit and chronic care
management services (99336, 99491) provided on February 5, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the established patient assisted living visit and chronic care management
services. You say that the services provided were medically necessary. The Plan denied your request. The Plan
says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly
denied.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the established patient assisted living visit and
chronic care management services (99336, 99491) provided on February 5, 2020, by an out of network (OON)
provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 9, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 has network providers available who can provide 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 doesnot have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis billed with code L0650 for date of service June 11, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that the documentation provided supports the medical necessity of the item in dispute.The Plan denied your request. The Plan says the documentation provided does not show that the criteria for coverage have been met.The Plan must follow Medicare rules. Medicare rules say that a treating practitioner must have a face-to-face encounter with a beneficiary within the six (6) months prior to prescribing durable medical equipment.
We looked at the file and Medicare rules. The case file did not include progress notes showing that an exam was done within 6 months prior to the date the orthotic in dispute was prescribed. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis billed with code L0650 for date of service June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea four-folding white cane.You asked the Plan to pre-approvethese services. You say that you are homebound and need the item.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea four-folding white cane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordurable medical equipment provided to the enrollee from March 27, 2020, to June 26, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted doesThe Plan must follow Medicare rules. Medicare rules say that DME requires a written order. There is no valid physician order in the case file. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordurable medical equipment provided to the enrollee from March 27, 2020, to June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from July 18, 2019, through March 2, 2020.You asked the Plan to pay for the psychotherapy 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 psychotherapy services. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from July 18, 2019, through March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).You asked the Plan to pre-approvea CGM. You say that you have poor circulation in your fingers and it results in inaccurate readings.The Plan denied your request. The Plan says that a continuous glucose monitor is not covered for member not on insulin.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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for thromboplastin time testing (85730) provided on January
23, 2020.
You asked the Plan to hold you harmless for thromboplastin time testing. You say that these tests were
supposed to be covered. The Plan denied your request. The Plan says that this test was billed with an incorrect
modifier.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
The thromboplastin time testing at issue was provided by a contract provider. The file does not show that the
Plan provided notice that thromboplastin time testing would not be covered. Under Medicare rules, this means
thromboplastin time testing is considered approved by the Plan. Therefore, we decided that the Plan has to hold
you harmless for thromboplastin time testing (85730) provided on January 23, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (0042T) provided on June 16, 2020.You asked the Plan to pay forthe services. The Plan deniedyour request. The Plan says these services are not covered.The Plan must follow Medicare rules. Medicare rules say that LCA A56967 provides a list of CPT codes that are considered not reasonable and necessary. We looked at the file and Medicare rules. Per A56967, CPT code 0042T is not considered medically reasonable and necessary, and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that thePlan does not have to pay forthe services (0042T) provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged services (99356) provided.

You asked the Plan to pay for prolonged services. You say that this is supported in the records.The Plan denied your request. The Plan says the time spent on these services is not documented.

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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service). 

We find that CPT code 99356 is not supported in the medical record. Specifically, the time spent on these services is not documented in the submitted medical records. Without this information, prolonged services cannot be verified. Based on this information, we decided that Medicare rules for coverage of prolonged services have not been met.Therefore, we decided that the Plan does not have to pay for prolonged services (99356) provided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on November 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.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 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 12, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. You also say that the treating physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that the enrollee was referred by his non-participating outpatient nursing facility.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 12, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesclerotherapy and endovenous ablation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation states that the enrollee is doing well, wearing compression stockings, and is not particularly interested in receiving treatment. There is no documentation of significant symptoms. There is also a history of diabetes and hypertension and the absence of significant peripheral artery disease has not been satisfactorily demonstrated. The services are not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvesclerotherapy and endovenous ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (scooter).

You asked the Plan to pre-approve power mobility device. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not show that the enrollee's home was evaluated to ensure that a power mobility device would fit and could be used safely.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 power mobility device. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested scooter. Our physician reviewer found the documentation does not reveal that the enrollee has a personal mobility deficit that impairs mobility-related activities of daily living (MRADLs) such as housework, bathing, dressing, or toileting. He has trouble with meal preparation and shopping, but it is not clear that his mobility deficit impairs participation in MRADLs in the home. It is unclear why the enrollee is unable to use a manual wheelchair. The documentation reveals the enrollee has the cognition to safely operate a power mobility device, but there is no in-person assessment in the home to evaluate that he can safely maneuver the power mobility device within the home.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power mobility device have not been met.Therefore, we decided that the Plan does not have to pre-approve a power mobility device (scooter).