Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 15 with an oral surgeon.

You asked the Plan to pre-approve the dental service. You say that you feel this service should be covered. You also say that you are concerned that your tooth may break off. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist. The Plan also says that dental service performed by an oral surgeon are not covered.

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 services not performed by a participating general dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 15 with an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hizentra.

You asked the Plan to pre-approve Hizentra. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

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 Hizentra.

Benefits for Hizentra 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (81295, 81298, 81201, 81317, 81403, 81404, 81406, 81185, 81405, 81432, 81479) provided on August 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not covered.

The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Medicare rules also say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. Medicare rules also say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 

Codes 81295 and 81298 are part of an edit pair with procedure code 81432. Procedure code 81432 is a column one code, and codes 81295 and 81298 are column two codes. Procedure code 81432 has been billed for this date of service, which means that procedure codes 81295 and 81298 are not eligible for payment. Based on this information, we decided that Medicare rules for coverage of codes 81295 and 81298 have not been met. 

Additionally, the documentation shows that the claim for codes 81201, 81317, 81403, 81404, 81406 and 81185, was billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of codes 81201, 81317, 81403, 81404, 81406 and 81185, have not been met. 

Finally, in this case, the requested genetic testing (81405, 81432, 81479) was billed with multiple codes. Per Medicare rules, this testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of codes 81405, 81432, and 81479, have not been met. Therefore, we decided that the Plan does not have to pay for the services (81295, 81298, 81201, 81317, 81403, 81404, 81406, 81185, 81405, 81432, 81479) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on January 5, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on January 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that please review attached and process your claim for payment. 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 domiciliary or rest home visit (99335) provided on January 6, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit (99283) provided August 27, 2020.

You asked the Plan to pay for the emergency visit. You say that enclosed are copies of the emergency department records and the physician reports supporting the enrollee presented for treatment and the service provided was reasonable and appropriate. The Plan denied your request. The Plan says the diagnosis is not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99283 is evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history, an expanded problem focused examination; and medical decision making of moderate complexity. 

We find that CPT code 99283 is not supported in the medical record. Specifically, diagnosis K06.8: other specified disorders of gingiva and edentulous aveolar ridge, is not covered. These services involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. The following services are excluded under Part B: A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw. A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non&#8208;dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process) These are dental services that are not covered or paid for by Medicare. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room visit (99283) provided August 27, 2020.
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 you therapy need and close monitoring. The Plan denied your request. The Plan says you can be treated at a lower level of care.

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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

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.
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 IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the patient was admitted for surgical treatment of bilateral lower leg fractures
after a motor vehicle collision. Medical problems are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a
reasonable expectation that this patient 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rybelsus.
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 Rybelsus.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Faslodex (J9395).

You asked the Plan to pre-approve Faslodex. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for drugs under the Medicare Part B have not been met.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve treatment with Faslodex (J9395).

Benefits for Faslodex 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: 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 IRF care is medically necessary and reasonable. The Plan denied your request. The Plan says rules for IRF care have 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 patient was admitted for congestive heart failure, pneumonitis, and coronavirus infection and was discharged home on August 21, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of prostate cancer, hypertension, and osteoporosis. He has not tried and failed the Plan's required drug, bisphosphonate therapy. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and the portable gaseous oxygen system provided from February 15, 2021, to May 15, 2021.

You asked the Plan to waive the coinsurance for the oxygen concentrator and the portable gaseous oxygen system. You say that you have been receiving the equipment for four years and you should not be charged. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered benefits.

You have been asked to pay a total of $99.76 which is 20% of the total allowed amounts for the oxygen concentrator and the portable gaseous oxygen system. The allowed amount for the oxygen concentrator is $104.31. ($104.31 x 20% = $20.86). ($20.86 x 4 dates of service = $83.44). The allowed amount for the portable gaseous oxygen system is $20.41. ($20.41 x 20% = $4.08). ($4.08 x 4 dates of service = $16.32). ($83.44 + $16.32 = $120.63). The oxygen concentrator and the portable gaseous oxygen system falls within the "Durable Medical Equipment (DME) and Related Supplies" benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and the portable gaseous oxygen system provided from February 15, 2021, to May 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint interventions.
You asked the Plan to pre-approve facet joint interventions. You say that your spine is deteriorating, and you are in severe pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you did not have the minimal pain reduction required to approve this procedure.
The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain circumstances. 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 facet joint interventions. Our reviewer says that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found you have chronic neck pain. Your magnetic resonance imaging (MRI) shows prior anterior cervical fusion at C3-C-4 as well as multi-level degenerative disc disease and foraminal stenosis. You received 2 sets of diagnostic medial branch blocks and achieved 50% to 60% pain relief. These medial branch blocks did not achieve 80% pain relief as required by Medicare rules. Therefore, this request is not considered 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 facet joint interventions have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint interventions
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom foot orthotics (CPT code(s): L2999 and L3216).

You asked the Plan to pre-approve the custom foot orthotics. You say that it is hard to get a shoe over your brace. You state your left leg has a lot of bandage and swells with the brace on as you have to go up two (2) shoe sizes which makes your shoe on the right too big and has to be stuffed with layers of foot pads. The Plan denied your request. The Plan says the requested orthotic is not an integral part of a brace and you are not diabetic.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the custom foot orthotics (CPT code(s): L2999 and L3216).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

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. It appears that the plan's contracted delegate was provided the records for this service and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), 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.