Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services (S5101).

You asked the Plan to pre-approve the adult day care services. You say that you need coverage for an adult day care program. The Plan denied your request. The Plan says adult day care services are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adult day care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve adult day care services (S5101).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for emergency room services (99282 and A9270) provided on November 8, 2020.
You asked the Plan to pay for the emergency room services. You say that you would like reconsideration because you were within your rights to be seen immediately by a professional. The Plan denied your request. The Plan says that the diagnosis billed is not covered under your Part B medical plan per CMS guidelines.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the documentation submitted does not include any clinical information to validate that this service should be considered a dental service. We are unable to verify if prudent layperson standards were met based solely on a diagnosis code. You went to the emergency room due to a potential medical emergency. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for emergency room services (99282 and A9270) provided on November 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided
on December 27, 2020.

You asked the Plan to pay for the continuous glucose monitor supply allowance (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says per supporting documentation provided by the supplier the criteria is not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the physician did not mention ordering a CGM and the enrollee has not had a 6 month in-person visit to assess adherence to the CGM regimen. Based on this information, we decided that Medicare rules for coverage of the CGM supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on December 27, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx.

You asked the Plan to pre-approve Supartz Fx. The Plan denied your request. The Plan says the enrollee has not tried and failed Durolane, Gelsyn-3, and Synvisc.

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 looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the enrollee has tried and failed Durolane, Gelsyn-3, and Synvsic. There is no documentation to show that the Plan's required drugs are likely to be less effective or will likely have adverse effects on the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray
(D0220), and bitewing x-ray (D0270) provided on October 2, 2020.
You asked the Plan to pay for the dental services. You say that no one told you that your insurance was not
going to cover anything. You also say that the doctor was very unprofessional. The Plan denied your request.
The Plan says limited oral evaluation is not listed and therefore is not a covered service. The Plan says that
periapical x-ray is not listed as a covered service either. The Plan says that 1 set of bitewing x-rays are covered
per year. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on February 2, 2020. Additionally, the limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and bitewing x-ray (D0270) provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on June 4, 2020.

You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, code 99152 cannot be verified. The documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, code 99153 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on June 4, 2020.
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 not medically necessary. The Plan
denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately
treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.

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 is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services
at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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: Favorable

We decided that the Plan has to pay for genetic testing provided on October 7, 2020.You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels -except the basic lipid panel -for symptomatic patients with suspected or documented cardiovascular disease.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on October 7, 2020.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the change of the ureterostomy tube or externally accessible ureteral stent (50688) provided on December 1, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $150 copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center.
You have been asked to pay a $150 copayment for the Medicare-covered outpatient surgery provided at an in-network hospital. 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 change of the ureterostomy tube or externally accessible ureteral stent (50688) provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided
on November 13, 2020.

You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on November 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit, typically 60 minutes (CPT code 99350) provided to the enrollee on March 19, 2021, by an out-of-network provider.
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 this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 established patient home visit, typically 60 minutes (CPT code 99350) provided to the enrollee on March 19, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).
You asked the Plan to pre-approve Ilumya. You say that the enrollee is not getting any improvement with
topicals alone. The Plan denied your request. The Plan says the information submitted does not meet the Plan's
medical necessity guidelines for coverage.
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 Ilumya. Our reviewer says that Ilumya
(J3245) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the
medical records provided the enrollee has not tried and failed the required drugs, Inflectra or Remicade and
Stelara. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less
effective and/or likely have adverse effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya (J3245).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that these tests resulted from services rendered by a participating physician.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prescription drug, oral, non-chemotherapeutic (J8499), provided on July 7, 2020.
You asked the Plan to waive the coinsurance for the prescription drug. You say that the item should be covered. 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 prescription drug. prescription drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the prescription drug, oral, non-chemotherapeutic (J8499), provided on July 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on November 21, 2020, through November 25, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be covered. 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 $393 copayment each day one through five for inpatient hospital care. 

You have been asked to pay a $393 copayment each day one through five for inpatient hospital care. inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on November 21, 2020, through November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance.
You asked the Plan to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had a multi-level lumbar laminectomy in 2010.
The enrollee's physical exam confirms left sacroilitis. The enrollee had a diagnostic left sacroiliac joint injection and had 80% pain relief. The request is for radiofrequency ablation of the lateral sacral branches. Radiofrequency ablation of the lateral sacral branches is considered an experimental/ investigational procedure. Therefore, the enrollee does not meet criteria for the requested 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 radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.