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

We decided that the Plan does not have to reduce the coinsurance for the Part B drug.

You asked the Plan to reduce the coinsurance for the Part B drug. You say that the coinsurance should be reduced because that is not the cost that was originally quoted on the Plan's website. The Plan denied your request. The Plan says their website quoted you a Tier 3 drug which was on the Part D side of your plan. You have been asked to pay 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 Medicare Part B chemotherapy prescription drugs.

You have been asked to pay $176.56 which is 20% of the allowed amount for the Part B drug. The allowed amount is $882.78. ($882.78 x 20% = $176.56). The Part B drug 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 reduce the coinsurance for a Part B drug.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider.

You asked the Plan to pay for the home visit. You say that a health plan should reimburse providers to care provided to its enrollee until the care results in stabilization. You say that the claim should be processed for payment. The Plan denied your request. The Plan says the services were not authorized.

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 for the home visit provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery (29877, 29881).

You asked the Plan to pre-approve knee surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had a documented trial of conservative therapy.

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 knee surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no detailed documentation regarding any trial and failure of less invasive care measures. The requested procedure is not supported in the absence of failure of line procedures in the absence of mechanical symptoms, which are not documented. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee surgery (29877, 29881).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on October 29, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you do not feel that you should be responsible for this payment. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on February 19, 2020, and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye refractions (92015).

You asked the Plan to pay for the eye refractions. You say that the requested service was necessary. The Plan denied your request. The Plan says that the requested service is not covered.

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 these services when performed once every two years.

We looked at the file and the Plan's rules. The Plan contract specifically states that the Plan covers routine exams up to 1 every 2 years, including code 92015. Based on this information, we decided that the Plan's rules for coverage of the eye refractions have been met. Therefore, we decided that the Plan has to pay for the eye refractions (92015).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need an intensive rehab program.

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 admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. 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 respiratory failure, COVID 19 infection, and pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 18, 2020.

You asked the Plan to pay for laboratory services. You say that your primary physician ordered these tests. You say that you were unaware prior approval was required. The Plan denied your request. The Plan says prior authorization is required for out-of-network services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 for laboratory services provided by an out-of-network provider on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.

You asked the Plan to pre-approve the requested device. You say that conservative treatment has failed. The Plan denied your request. The Plan says the device used as treatment for neurogenic intermittent claudication is considered investigational.

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 requested device. Our physician reviewer found that the requested device is considered experimental. More research is needed to show its safety and efficacy. Therefore, the requested device is not medically reasonable and 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on September 12, 2020.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable under the enrollee's contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and night differential are no longer paid separately for ambulance services. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance oxygen and supplies have not been met. Specifically, the ambulance oxygen and oxygen supplies are not separately payable from the ambulance transport. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on September 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for diarrhea, hypotension and dehydration. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acupuncture services.

You asked the Plan to waive the copayment for the acupuncture services. You say that you were reimbursed in full for these services. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.

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 s $15 copayment for acupuncture.

You have been asked to pay s $15 copayment for the acupuncture services. The acupuncture services fall within the acupuncture 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 acupuncture services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services.

You asked the Plan to pay for the inpatient services. You say that there was not any neglect in treatment that caused this unavoidable readmission. The Plan denied your request. The Plan says that the enrollee was previously treated for the same condition.

The Plan follows Medicare rules. Medicare rules say that hospital readmissions are only covered under certain medical indications.

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 the inpatient services. Our physician reviewer found that the enrollee was admitted with worsening infections and bronchoscopy with significant increase in purulent secretions, fatigue and decreased oxygenation requiring further evaluation and IV antibiotics. He was also admitted for further management of fungal disease that was found on the bronchoscopy, which was performed during his first hospitalization. Therefore, the readmission was medically necessary and was not the result from a premature discharge from the same hospital.

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 inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on July 14, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation (D7953), the surgical extraction (D7210), and the unspecified preventive service (D1999) provided on October 5, 2020.

You asked the Plan to pay more for the dental services. You say that you had a loose crown. You say that the crown fell out, pin and all, while you were waiting for your appointment that was delayed. You say that you had to have a bone graft done. You say that you thought this had been approved and paid. You say that you paid a copayment of $240. You also say that you should not be responsible for the $2,266 charges. The Plan denied your request. The Plan says there is a 50% coinsurance for Class 3 Major Services, including surgical extractions and bone grafts.

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 and the services are listed as covered, there is a 50% coinsurance for Class 3 Major Services. The record shows that the Plan paid $254 toward the services. You are responsible for the remaining amount of $249. The record shows that the Plan confirmed that you are not responsible for the $2,266 charges. Additionally, unspecified preventive service is not listed and therefore is not a covered service. Therefore, we decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation (D7953), the surgical extraction (D7210), and the unspecified preventive service (D1999) provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA).

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 the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PVA is covered when specific criteria are met.

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 enrollee has a history of osteoporosis and cancer. There is no documentation of adequate conservative measures, including a trial of bracing. The criteria for vertebral augmentation with cement are not met; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M).

You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says this service is non-covered under Medicare.

The Plan must follow Medicare rules. Medicare rules say that CPT code 0012M, CxBladder testing, is not a covered service.

We looked at the file and Medicare rules. The service performed is not currently covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested services are medically necessary for the enrollee. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. 

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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for disposable underpads (A4554).

You asked the Plan to pay for incontinence supplies. You say that the requested protective bed barriers are recommended by your physician as a continued care item of necessity. The Plan denied your request. The Plan says the requested items are not covered under Medicare or the Plan.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for disposable underpads (A4554).