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

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 15, 2020.

You asked the Plan to pay for the dental service. You say that your provider requested a panoramic x-ray. You say that you are on a limited income. You also say that you did not know what type of x-ray was done previously. The Plan denied your request. The Plan says 1 complete series or 1 panoramic x-ray is covered per calendar year. The Plan also says that the benefit for this service 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, the frequency limit has been exceeded. The Evidence of Coverage clearly states that 1 complete series x-ray or 1 panoramic x-ray is covered per calendar year. The record shows that the Plan paid for a complete series x-ray that you received on July 27, 2020. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with an out of network (OON) oncologist.

You asked the Plan to pre-approve the OON oncology visits. You say that you have had CT scans and mammograms. You say that you were diagnosed with breast cancer in November of 2020 and the in-network doctor has not done anything for you. The Plan denied your request. The Plan says there are providers within the network that can meet the enrollee's medical needs, provide a second opinion, and supply necessary treatment.

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 care that cannot be provided by network providers. Medicare rules say that documentation must be submitted to show that coverage criteria have been met. 

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. We found that there were no medical records submitted to show that there is anything unique about your condition that would make it medically necessary to see the out of network provider. We found that the Plan made reasonable attempts to obtain medical records, unsuccessfully. We found no exception that would require the Plan to pre-approve OON care. Therefore, we decided that the Plan does not have to pre-approve office visits with an out of network (OON) oncologist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was 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 June 5, 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 June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from September 14, 2020, to September 22, 2020.

You asked the Plan to waive the copayments for inpatient hospital stays. You say that you feel that the enrollee was discharged too soon and should only be charged one inpatient hospital copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $360 copayment for days 1-5 for inpatient hospital care. 

The enrollee had an inpatient hospital stay from September 14, 2020, to September 17, 2020. Therefore, the enrollee is responsible to pay the total copayment amount of $720, which is less than the total copayment amount. 

The enrollee had an inpatient hospital stay from September 19, 2020, to September 22, 2020. This is considered a new inpatient hospital admission. Therefore, the enrollee is responsible to pay a $360 copayment for days 1-3 (September 19, 2020, to September 21, 2020). $360 (copayment) x 3 (inpatient days) = $1,080.

The total amount the enrollee owes is: $1,800.

The enrollee has been asked to pay the total copayment amount of $1,800 for inpatient hospital stays. Inpatient hospital stays fall within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from September 14, 2020, to September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on September 4, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of chronic kidney disease, monoclonal gammopathy of uncertain significance, coronary artery disease and anemia (hemoglobin level 11.2 grams/dL and hematocrit 35.1% as of January 19, 2021). Based on the medical records provided and the Medicare-approved drug compendia, initiation of Retacrit is not recommended for anemia of chronic kidney disease unless the hemoglobin level is less than 10 grams/dL. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on August 18, 2020.

You asked the Plan to pay for the outpatient office visit. You say that the treatment provided was medically necessary. You also say that the enrollee had been discharged from hospice on August 18, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray rendered on September 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 73501 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 73501 and 73502. Code 73501 is a column II code with a modifier indicator of 1 when billed with column I code 73502. Code 73501 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the hip x-ray rendered on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital admission.

You asked the Plan to pre-approve the inpatient admission. You say that you feel that this surgery should be allowed to proceed in the inpatient setting. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. There is no evidence at this time that more than two midnights of hospital care will be required.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is scheduled to undergo a shoulder surgery after failure of conservative treatments. The record does not show that the admitting physician reasonably expects that the patient's necessary hospital care will span two midnights. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed at that 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services and laboratory services provided on August 18, 2020 and September 29, 2020.

You asked the Plan to pay for the physician's services and laboratory services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 physician's services and laboratory services provided on August 18, 2020 and September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc injection services.

You asked the Plan to pre-approve Genvisc injection services. You say that the requested drug is medically necessary and supported by the records provided. The Plan denied your request. The Plan says the enrollee does not meet the step therapy requirement and there is no information explaining why the enrollee can't have one of the formulary choices.

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 Genvisc injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic left knee pain. She takes Gabapentin and Soma for pain. On physical exam, she has positive findings for osteoarthritis, but X-rays do not support that diagnosis. Our physician reviewer found that the Plan requires a trial of drugs Euflexxa, Supartz, Durolane, or Gelysn before they will approve the requested drug and that the enrollee has not tried and failed these required drugs. Genvisc has not been previously used on the enrollee and is a new prescription. There is nothing in the medical records that shows the Plan's preferred medications would be contraindicated.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc injection services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable x-ray provided on January 14, 2019.

You asked the Plan to pay for the portable x-ray. You say that your office suffered severely, and the attendance of employees was greatly compromised due to the global pandemic. You say that you are putting in the greatest effort to submit all claims in a timely manner. The Plan denied your request. The Plan says the claim denied correctly, as it was not received within the allowed timeframe for filing.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the portable x-ray was not filed until September 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a portable x-ray provided on January 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.

You asked the Plan to pre-approve IRF services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. Medicare rules say that IRF services have specific coverage criteria. Our Physician Reviewer says that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 services are not met. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan Acid Therapies for the enrollee.

You asked the Plan to pre-approve Hyaluronan Acid Therapies. You say that Hyaluronan Acid Therapies are medically necessary. The Plan denied your request. The Plan says the required step therapy criteria are not met.

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 Hyaluronan Acid Therapies. Our reviewer says that step therapy criteria are not met. Our physician reviewer found the Medical records received showed that the enrollee has bilateral knee osteoarthritis with complaints of bilateral knee pain. He was recommended for Monovisc injection. But, medical records did not indicate if the patient has had conservative therapy treatment such as nonpharmacologic therapy and simple analgesics or NSAIDS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan Acid Therapies have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan Acid Therapies for the enrollee.
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 this denial is contradictory to the best outcome and appropriate care for the enrollee. You say that a skilled nursing facility level of care would prolong the enrollee's illness and be detrimental to her ability to regain her prior level of independence. The Plan denied your request. The Plan says IRF care is not medically necessary in this case. The Plan says that the enrollee can get the therapy needed 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 above. 

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sacral and pubic fractures after a fall. Non-operative management was recommended. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99211) provided on March 5, 2020.

You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99211 has a status indicator of B meaning it is not payable under OPPS.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99211 is not supported in the record. Specifically, per Medicare, CPT code 99211 has a status indicator of B. This means that CPT code 99211 is not payable under OPPS or when submitted on an outpatient hospital bill type. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99211) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation or inpatient hospital care (99235) provided July 15 2019.

You asked the Plan to pay for the hospital services. You say that you did not receive proper notice of this enrollee's benefit determination, hence, the untimely submission of the claim. The Plan denied your request. The Plan says this claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the hospital services was not filed until September 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the observation or inpatient hospital care (99235) provided July 15 2019.