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

We decided that the Plan has to pay for advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of such forms, when performed), by the physician
or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s),
and/or surrogate (CPT Code 99497) provided on May 20, 2019.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says that the services are not supported by the records.

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 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 services. Our physician reviewer found
the documentation from the office evaluation indicates that advanced planning took place with the enrollee and
their family. Advance care planning including the explanation and discussion of advance directives such as
standard forms (with completion of such forms, when performed), by the physician or other qualified health
care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT
Code 99497) provided on May 20, 2019. The review has determined that the service was supported in the
records.

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 services have been met. Therefore, we decided that the Plan has to pay for
advance care planning including the explanation and discussion of advance directives such as standard forms
(with completion of such forms, when performed), by the physician or other qualified health care professional;
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT Code 99497) provided
on May 20, 2019.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart evaluation (93460) to be provided by an out-of-network provider.
You asked the Plan to pre-approve a heart evaluation to be provided by an OON provider. You say that the
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able
to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a heart evaluation (93460) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) provided to the enrollee on August 6, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that thePlan does not have to pay forthe knee orthosis (L1833) provided to the enrollee on August 6, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implanted infusion pump refill with baclofen and services to be provided by an out-of-network provider.
You asked the Plan to pre-approve infusion pump services. You say that these services are greatly needed for you. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network and you can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve implanted infusion pump refill with baclofen and services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinjection of onabotulinumtoxina (J0585) provided on March 18, 2020.You asked the Plan to waive the copayment forinjection. You say that you should not be responsible for the cost share.The Plan denied your request. The Plan says the cost share was applied 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for an injection. This service 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 copayment forinjection of onabotulinumtoxina (J0585) provided on March 18, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Denosumab (J0897).

You asked the Plan to pre-approve Denosumab. The Plan denied your request. The Plan says that Denosumab is not medically necessary.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. 

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 Denosumab. Our reviewer says that Denosumab is medically reasonable and necessary for the enrollee. Our physician reviewer found Denosumab is Food and Drug Administration (FDA) approved for postmenopausal female with osteoporosis at high risk of fracture. This enrollee has a worsening DEXA despite being on Raloxifene. Our reviewer also found that the use of Denosumab is reasonable and 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 Denosumab have been met.Therefore, we decided that the Plan has to pre-approve Denosumab (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sacroiliac (SI) joint ablation provided on July 15, 2020.You asked the Plan to pay forthe SI joint ablation. The Plan denied your request. The Plan says this 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 pay for the SI joint ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that SI joint ablation is experimental. More research is needed to show safety and efficacy. The use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-term benefit over standard treatment for chronic sacroiliac joint pain.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 SI joint ablation have not been met.Therefore, we decided that the Plan does not have to pay forthe sacroiliac (SI) joint ablation provided on July 15, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pylera.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pylera.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesemi-electric hospital bed (E0260).You asked the Plan to pre-approvethe hospital bed. You say that the enrollee needs the hospital bed so that she may elevate the head of her bed or feet as needed to assist with her breathing.The Plan denied your request. The Plan says the records do not support that a semi electric hospital bed is medically necessary for the enrollee.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.Our physician reviewer found the documentation does not clearly reveal that enrollee's condition needs to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. There is a physician appeal that states that the enrollee needs to elevate the head and foot of the bed to help with breathing but it is not clear that it has to be most of the time or thirty degrees. There is no evidence of a frequent or immediate change in body position or an objective physical exam indicating that the enrollee can operate the controls.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 hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvesemi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 27, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that these services were medically necessary.The Plan denied your request. The Plan says rules for payment have notbeen met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on May 27, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 11, 2020, by an OON provider.You asked the Plan to pay fornursing facility psychiatric care. You say that the enrollee could not choose an in-network psychiatrist due to the place of residence.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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. Wefound no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 11, 2020, by an OON provide
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's records show that the enrollee is not medically stable because the enrollee's heart failure has not adequately stabilized and he still require intensive hospital treatments.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered as soon as is appropriate.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel One.You asked the Plan to pre-approveGel One. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the requested drug does not meet step therapy criteria.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 GelOne. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. Thedocumentation does not support that the required step therapy drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel One have not been met.Therefore, we decided that the Plan does not have to pre-approveGel One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on September 11, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that you should not owe a copayment for laboratory services.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 $0 copayment for lab services provided in a physician's office and a $30 copayment when provided at an outpatient hospital facility. You received laboratory services at an outpatient hospital facility on September 11, 2020. Therefore, you are responsible to pay the allowed amount of $18.33, which is less than the $30 copayment. You have been asked to pay $18.33 for laboratory services. Laboratory services fall 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 forlaboratory services provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee on August 21, 2020.
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your
request. The Plan says a secondary-only diagnosis cannot be used as the primary first-listed or principal
diagnosis for any procedure or service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that CPT code 99308 is not supported in the medical record. Specifically, this code was billed only
with a diagnosis code (F01.51) that is considered a secondary diagnosis code. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for skilled nursing facility (SNF) services provided to the enrollee on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided on January 6, 2020, through
April 5, 2020.
You asked the Plan to pay for the diabetic supplies. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a
valid physician's order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the
physician order supplied is dated after the date of delivery for the supplies at issue. 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 the diabetic supplies provided on January 6, 2020, through April 5, 2020.