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

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) provided by out of network provider, on June 24, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the Plan's denialas the physician rendered services to the enrollee given the urgent nature of the patient's condition.The Plan denied your request. The Plan says the services were provided by an outof 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care(99308) provided by the out of network provider on June 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (CPT Code E0265).
You asked the Plan to pre-approve total electric hospital bed. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. This type of hospital bed is not included as a Medicare covered benefit. Your doctor can ask for a semi-electric hospital bed. Therefore, we decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (CPT Code E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 19, 2019 by out of network provider.
You asked the Plan to pay for office visit. You say that this service was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve viscosupplementation injections (J7321x6).
You asked the Plan to pre-approve viscosupplementation injections. You say that the member has tried physical therapy, pain medications and cortisone injections with no improvement. The Plan denied your request. The Plan says the x-rays received are not supported by radiologic evidence of osteoarthritis of the knee.
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 viscosupplementation injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided indicate the member has only had 6 weeks of conservative therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of viscosupplementation injections have not been met. Therefore, we decided that the Plan does not have to pre-approve viscosupplementation injections (J7321x6).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on September 23, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that the brochure regarding the free eye exam did not have any information stating you would have a copayment when seeing an ophthalmologist. The Plan denied your request. The Plan says you have been charged 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 a $35 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The medical record shows diagnoses of cataracts and dry eye disease which makes the eye exam medical in nature.
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 eye exam provided on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.
You asked the Plan to pre-approve Xgeva. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered as requested.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Xgeva as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee has progressive terminal cancer. The Plan denied your request. The Plan says the requested provider is not in the enrollee's network.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric wheelchair.
You asked the Plan to pre-approve the electric wheelchair. You say that the electric wheelchair is medically necessary because the enrollee is very weak and is not able to stand or walk due to a stroke. The Plan denied your request. The Plan says a power mobility device is not medically necessary
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the electric wheelchair. Our reviewer says that this enrollee does not meet the medically necessary criteria for a power mobility device. Our physician reviewer found based on available records, the enrollee does not meet criteria for coverage of the power wheelchair. The enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living, however the clinical records document his mobility deficit can be helped by a manual wheelchair. 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 electric wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (J0129).
You asked the Plan to pre-approve Orencia. You say that the Orencia 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 Orencia. Our reviewer says that the
provided medical records do not indicate that the member has tried and failed a trial of Remicade or Inflectra
and Simponi Aria. Our physician reviewer found the record does not indicate that the Plan's required drugs
would likely be less effective and/or likely have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orencia (J0129).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric for the enrollee.
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 Uloric for the enrollee.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sumatriptan injection 6mg/0.5 for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested medication is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Sumatriptan injection
6mg/0.5 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on September 5, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the
documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, 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 the orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cataract surgeries or the specialist office visit provided on August 29, 2019 and September 12, 2019.
You asked the Plan to waive the cost share for the cataract surgeries and the specialist office visit. You say that you are being charged an additional $400. The Plan denied your request. The Plan says you have been charged 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 surgery services at an in-network ambulatory surgical center and a $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a total of $355.99 for the cataract surgeries and the specialist office visit. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the cataract surgeries were performed at an ambulatory surgical center and the specialist office visit was provided in an office setting. See chart below for cost sharing amounts.
Date of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
August 29, 2019
Cataract surgery
$847.07
20%
$169.41
September 12, 2019
Specialist office visit
$78.58
$50.00
$50.00
September 12, 2019
Cataract surgery
$682.92
20%
$136.58
Total
$355.99
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 cost share for the cataract surgeries or the specialist office visit provided on August 29, 2019 and September 12, 2019.
Your complaint about the deceptive billing practice is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam provided on September 17, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that this was an annual eye exam.The Plan denied your request. The Plan says 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 $35 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. Therecords show that this was a medical eye exam. 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, wedecided that the Plan does not have to waive the copayment forthe eye exam provided on September 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on June 10, 2019.You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 orthosis and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found 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 the LCD. 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 the orthosis and sleeve have not been met.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on June 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Scar Revision with a biologic Acellular Dermal Matrix implant.
You asked the Plan to pre-approve the procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that procedures and services performed using devices that have not been approved for marketing by the FDA are not covered unless part of an FDA-approved clinical trial. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Scar Revision with a biologic Acellular Dermal Matrix implant.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy (PT) in the acute hospital. The enrollee was at a supervision/standby assist to contact guard assist level for functional mobility including gait to 185 feet with a rolling walker. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a skilled nursing facility setting. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for SNF services.