Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833) and suspension sleeves (L2397).

You asked the Plan to pay for knee orthoses and suspension sleeves. You say that the requested items are medically necessary. The Plan denied your request. The Plan says there is no documentation of a relationship between the enrollee and the ordering physician.

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 knee orthoses and suspension sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. Bilateral knee braces were provided. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 orthoses have not been met. The requested suspension sleeves are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833) and suspension sleeves (L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01480).

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid primary diagnosis code.

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 code 01480 is not supported in the medical record. Specifically, the diagnosis code listed is not a valid primary diagnosis code. The associated condition must be listed first. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01480).
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 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 facility. 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 soon when treatment has completed.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the medical services related to cancer-related breast reconstruction billed over 9 claims.

You asked the Plan to make additional payment for the medical services. You say that you do not feel that you should be charged for the services related to your breast cancer reconstruction. You state that being charged for these violates the Women's Health and Cancer Rights Act (WHCRA) which requires all insurers to cover reconstruction related to mastectomies for breast cancer. The Plan denied your request. The Plan says all services related to the reconstruction have been covered by the Plan. The correct cost sharing has been applied per the contract.

Please note: We did review the language of the WHCRA as cited by the enrollee. This regulation only requires coverage for these procedures and does not provide any requirement to waive cost sharing for these services. All services were covered, and the cost sharing is the issue at appeal.

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 $40 copayment for specialist services, a $45 copayment for diagnostic procedures and tests, and a $400 copayment for outpatient surgery done in a hospital.

You have been asked to pay a $40 copayment for the specialist visits in the outpatient hospital. This is the correct copayment for specialist visits based on the 2019 EOC. You were also charged a $40 copayment for the two visits. You were provided with an electrocardiogram (EKG) with a $45 copayment. The EKG falls within the diagnostic procedures/tests benefit category. You were provided with outpatient surgery. Each of these surgeries were assessed the $400 copayment as per your contract.

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 make additional payment for the medical services related to cancer-related breast reconstruction billed over 9 claims.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cortisone injection you had in your doctor's office.

You asked the Plan to waive the copayment for the cortisone injections. You say that you don't feel as though you should have to pay this copayment since you had to pay a copayment for the office visit you had two days prior. The Plan denied your request. The Plan says you were charged this 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 $30 copayment for medical care or surgery services in a specialist's office.

You have been asked to pay a $30 copayment for the cortisone injections. The cortisone injections falls within the medical care or surgery services in a specialist's office benefit category. This copayment applies each time you receive care in your doctor's office, regardless of the reason for the visit. 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 you had in your doctor's office.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo the elective total knee arthroplasty. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 93970).

You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct diagnoses.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.

We find that this claim cannot be paid as billed. The services at issue were billed with diagnosis codes I83.92, varicose veins of the left lower extremity, and I83.91, varicose veins of the right lower extremity. There is a more appropriate bilateral code for the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214, 93970).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ruxience for the enrollee.

You asked the Plan to pre-approve Ruxience. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that the drug is not being prescribed for a medically accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Ruxience. Our reviewer says that Ruxience is medically reasonable and necessary for the enrollee. Ruxience is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets Medicare criteria for Ruxience.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ruxience have been met. Therefore, we decided that the Plan has to pre-approve Ruxience for the enrollee.

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 pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that this was for a Covid-19 test. The Plan denied your request. The Plan says prior authorization was not obtained.

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 physician services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222, D9223) and a diagnostic consultation (D9310).

You asked the Plan to pay for the anesthesia and diagnostic consultation. You say that you believed these services were covered and you cannot afford the bill. The Plan denied your request. The Plan says deep sedation/general anesthesia and a diagnostic consultation are not covered by Medicare or by the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222, D9223) and a diagnostic consultation (D9310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 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 a hip fracture after a fall. Your medical problems are stable. You do not have 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. 

Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary for the enrollee. Our physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is consistently ambulating more than one hundred feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's needs at this point are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 laboratory services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services (97803).

You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

The records provided do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services (97803).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 16 skilled nursing visits to be provided in the home health setting.

You asked the Plan to pre-approve the requested continued home health services. You say that you believe that ongoing intermittent skill nursing care is necessary for this enrollee's condition. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 continued home health services. Our reviewer says that the criteria for coverage of the requested continued home health care are not met. Our physician reviewer found the enrollee has been receiving skilled nursing home health. There is no indication that the member has a feeding tube, parenteral medications or complex wound care issues. There is no indication that the member had any recent medication changes or hospitalizations. There has not been a recent decline in function and the member has been medically stable.

In this case, the documentation does not support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health 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 the requested continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 16 skilled nursing visits to be provided in the home health setting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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 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 office visit provided by an out of network (OON) provider.