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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care. 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation and tracheostomy care, scheduled hemodialysis, surveillance laboratory studies, tube feeding, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88311, 85097, 88189, 88313) provided on August 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says modifier Q0 or Q1 must be appended to the clinical service for participants in a clinical research program within the previous or subsequent 30 days.
The Plan must follow Medicare rules. Medicare rules say that for routine costs and investigational items of clinical trials, providers must bill with modifier Q0 or Q1. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim has not been billed with the required modifier. Therefore, we decided that the Plan does not have to pay for the laboratory services (88311, 85097, 88189, 88313) provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown with dental code D6750 and pontic-porcelain fused with dental code D6241.
You asked the Plan to pre-approve dental codes D6750 and D6241. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D6750 and D6241 are not covered under 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, dental codes D6750 and D6241 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown with dental code D6750 and pontic-porcelain fused with dental code D6241.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnosis interview examination (90792) provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric services. You say that please reconsider the denial of claim for no authorization. The enrollee presented to psychiatry for an annual psychiatric evaluation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 psychiatric diagnosis interview examination (90792) provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health inpatient services.

You asked the Plan to pre-approve behavioral health inpatient services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has exhausted the lifetime inpatient psychiatric benefit and no further care can be provided.

The Plan must follow Medicare rules. Medicare rules say that coverage for inpatient psychiatric care is limited to 190-days in a patient's lifetime. The contract with the Plan also states this.

Based on the Medicare database, the enrollee has received 190 days of inpatient psychiatric care. As such, no further inpatient psychiatric coverage is available. Therefore, we decided that the Plan does not have to pre-approve behavioral health inpatient services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Takhzyro.
You asked the Plan to pre-approve Takhzyro. You say that the requested Takhzyro is medically necessary. The Plan denied your request. The Plan says that the requested Takhzyro 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 Takhzyro. Our reviewer says that the requested Takhzyro is medically necessary. Our physician reviewer found the review indicates that the enollee is with a history of Hereditary Angioedema, Breast cancer, allergic rhinitis, asthma and GERD. Her provider has requested Takhzyro. The U.S. Food and Drug Administration today approved Takhzyro (lanadelumab), the first monoclonal antibody approved in the U.S. to treat patients 12 years and older with types I and II hereditary angioedema (HAE). HAE is a rare and serious genetic disease that affects people with low levels of and poorly functioning C1-INH proteins in the body. This results in recurrent, unpredictable episodes of severe swelling in different areas of the body, including the stomach, limbs, face and throat. Takhzyro is a plasma kallikrein inhibitor that is used to prevent swelling attacks from occurring. Takhzyro is a fully human IgG1 monoclonal antibody made in recombinant Chinese Hamster Ovary cells. In this case the enrollee is maintained on daily therapy with Firazyr. The review has determined that the documentation supports that the requested Takhzyro is medically reasonable and necessary for the enrollee. The documentation supports that the requested Takhzyro is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Takhzyro have been met. Therefore, we decided that the Plan has to pre-approve Takhzyro.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services. You asked the Plan to pre-approve the continuation of SNF services. You say that the enrollee needs additional time in the facility to become more independent. You say that the enrollee is unable to care for herself and his home is not set up properly. The Plan denied your request. The Plan says the enrollee exceeds the mobility and activities of daily living criteria for continued stay at a SNF for skilled therapy. 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 the continuation of SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee was at a moderate to maximal assist level with functional mobility, including gait to 12 feet. The enrollee required varying assist with activities of daily living. The enrollee had ongoing cognitive deficits and mild aphasia. The enrollee tolerated a mechanical soft diet and thin liquids. The enrollee does not require skilled nursing or therapy services on a daily basis. There are no identifiable skilled nursing service needs or identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 29, 2020. You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiomyopathy gene panel (81286, 81404, 81407, 81408,
81479) provided on June 10, 2020.
You asked the Plan to pay for a cardiomyopathy gene panel. You say that this was medically necessary. The
Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients
with suspected or documented CV disease because panel testing is not specific to a given patient's lipid
abnormality or disease.
We looked at the file and Medicare rules. The testing at issue is considered to be a CV risk assessment, and
billed diagnoses indicate that the enrollee is symptomatic. Based on this information, we decided that Medicare
rules for coverage of a cardiomyopathy gene panel have not been met. Therefore, we decided that the Plan does
not have to pay for a cardiomyopathy gene panel (81286, 81404, 81407, 81408, 81479) provided on June 10,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429) provided on September 27, 2019.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not billed according to CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code A0429 is not supported in the record. Specifically, in cases where the member is pronounced dead after the ambulance is dispatched, providers must report CPT code A0428. This claim was not billed with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0429) provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 14, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no claim for 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for lumbar spondylosis without myelopathy or radiculopathy; muscle weakness; lower back pain. Progress note dated 9/4/20 states 20-year history of back pain that is constant. The pain is achy and worsens with movement. Pain is caused by osteoarthritis, rheumatoid arthritis and is described as constant. Exam reveals standing, walking, laying worsens the pain. Aside from plausible efficacy in the relative acute injury phase, lumbar supports have not been proven efficacious in long term studies. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the brace was not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.

You asked the Plan to pre-approve Supartz. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception 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 Supartz. Our reviewer says that the Health Plan requires a trial of Synvisc or Euflexxa before they will approve Supartz. Our physician reviewer found there is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for glasses air conduction (V5070) provided November 19, 2019 to December 12, 2019
You asked the Plan to pay for the vision services. You say that this is your 6th attempt to get reimbursement for purchase of prescription glasses that the Plan agreed to pay for after cataract operations. The Plan denied your request. The Plan says the plan will cover for 1 pair of eyeglasses or contact lenses after each cataract surgery.
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 one pair of eyeglasses after cataract surgery. The plan reprocessed the claim and approved to reimburse $196.90 towards the cost of 1 pair of eyeglasses. The plan will not reimburse for the cost of the second pair of eyeglasses. We looked at the file and the Plan's rules. The plan will cover for 1 pair of eyeglasses or contact lenses after each cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for glasses air conduction (V5070) provided November 19, 2019 to December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 27, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 27, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care.

You asked the Plan to waive the copayment for the inpatient care. You say that you should not have to pay this bill because you fell in the hospital parking lot. The Plan denied your request. The Plan says inpatient services were provided, and the copayment 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 $95 copayment for each of the first 5 days of for inpatient hospital care.

You have been asked to pay a $190 copayment for two days of inpatient care ($95 x 2 = $190). 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 inpatient hospital care.

Please note that a possible issue with the safety of the hospital property is not a valid appeal for Medicare coverage and this complaint should be directed to the hospital.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care.

You asked the Plan to pay for the inpatient hospital care. You say that the claim was correctly billed. The Plan denied your request. The Plan says that DRG 177 is not supported in the records, DRG 193 is more appropriate in this case.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 177 is defined as Respiratory Infections and Inflammations with Major Complication or Comorbidity.

In this case, you billed the services provided with DRG 177. 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 hospital care. Our reviewer says that the records support DRG 177. Our physician reviewer found in this case, the enrollee decompensated on an antibiotic that would normally cover a community acquired pneumonia. Furthermore, culture results are frequently negative when a patient is already on antibiotics or have recently completed a course of antibiotics. The enrollee recently was treated for pseudomonas and presented with multifocal airspace disease, a common finding with pseudomonas pneumonia. The enrollee's presentation supports DRG 177.

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 hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital care.

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.