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

We decided that the Plan does not have to pay for the nursing care services coded S9124 provided on January
7, 2020.

You asked the Plan to pay for the nursing care 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 payable.
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 S9124 is nursing care, in the home; by licensed practical
nurse, per hour.

We find that CPT code S9124 is not supported in the medical record. Specifically, this code has a status code
of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another
code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the nursing care services have not been met. Therefore, we decided that the Plan does not have to pay for the nursing care services coded S9124 provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 1,
2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you were not informed that you
had a 90 day period after surgery that covered copayments. The Plan denied your request. The Plan says the
claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $45
copayment for each specialist visit.

You had a specialist visit on March 1, 2021. Follow-up visits are subject to cost-sharing charges. Therefore,
you are responsible to pay the $45 copayment.

You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on March 1, 2021.

We note your complaint that you were not informed that there was a 90 day global period on surgeries. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve a Freestyle Libre. You say that testing twice a day is very inconvenient and
that irregular readings put your health at risk. The Plan denied your request. The Plan says rules for a
continuous glucose monitor have not been 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 you do not perform blood glucose
testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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.

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 no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an intraoral periapical radiographic
image (D0220), and re-cement or re-bond of a crown (D2920) provided on January 26, 2021.

You asked the Plan to pay an additional amount for an intraoral periapical radiographic image, and re-cement
or re-bond of a crown. You say that you want the Plan to pay an additional amount towards the services. The
Plan denied your request. The Plan says the claims for these services were processed correctly with the
applicable out-of-network allowable amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image, and re-cement or re-bond of a crown have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for an intraoral periapical radiographic image (D0220), and re-cement or re-bond of a crown (D2920) provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit 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 step therapy criteria were not followed.

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 the drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the review indicates that the enrollee has CKD stage 5 and associated severe anemia of CKD with hemoglobin less than 9. His iron is replete. This is a standard indication of EPO. The plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve the requested device. You say that the enrollee has comorbidities that require the use of a CPAP machine. The Plan denied your request. The Plan says Medicare criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at this physician's review, the file, and Medicare rules. The records do not show that a replacement device is necessary due to loss or irreparable damage. 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 a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek diabetic test strips.

You asked the Plan to pre-approve Accu-Chek diabetic test strips. You say that you have been using the requested items for about a year and you do not want to change. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Accu-Chek diabetic test strips have not been met. Specifically, the Plan requires the trial of OneTouch-branded test strips before alternative brand names can be considered. There is no documentation in the case record to support a trial of OneTouch products. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe 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 drug is being pharmacy dispensed directly to to the enrollee. 
 
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 Prolia 60 mg/ml syringe for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calcitriol.

You asked the Plan to pre-approve Calcitriol. You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says this is not a separately payable benefit.

The Plan must follow Medicare rules. Medicare rules say that ESRD drugs are not separately payable as they are covered under the ESRD benefit. 

We looked at the file and Medicare rules. In this case, the requested drug should be covered under your ESRD payment and not separately payble. Based on this information, we decided that Medicare rules for coverage of Calcitriol have not been met. Therefore, we decided that the Plan does not have to pre-approve Calcitriol.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluid Flow injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says more research is needed to show the safety and efficacy of this injection 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has lumbago with sciatica. The provided records indicate that the 
enrollee is receiving other therapies that are standard for the enrollee's clinical scenario. The requested service 
has not been shown in the literature to be safe and effective for the enrollee's condition. 

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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Fluid Flow injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Aide services.

You asked the Plan to pre-approve Home Health Aide services. You say that you cannot get up and down the stairs since surgery and you have no assistance. The Plan denied your request. The Plan says the requested services are basic household assistance.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 Home Health Aide services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee does not appear to be homebound. As such, HHS, including HHA services, are not shown to be medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Home Health Aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Aide services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 36 additional routine transportation trips.

You asked the Plan to provide additional routine transportation trips. You say that you do not have any other means to get around to your appointments. The Plan denied your request. The Plan says you have used 36 of the allotted 36 one-way trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 36 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (Current Procedural 
Terminology (CPT) code L8702), for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that the enrollee had a hemorrhagic stroke in 2014 and 
the stroke resulted in the enrollee having residual left arm weakness and spasticity. You state the resultant 
weakness and spasticity limits the enrollee's functionality as they are unable to use their left arm for 
employment purposes and is unable to return to work. The Plan denied your request. The Plan says a review of 
current medical literature shows that these service(s) do not have proven benefit and are considered 
experimental/investigational. The Plan states they are not identified as widely used and generally accepted for 
the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the 
English language. 
 
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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee suffered a stroke in 2012 that resulted in left hemiparesis 
with spasticity. The provided medical records are insufficient to demonstrate the medical reasonableness and 
necessity of the requested service as defined by Medicare rules. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro Motion G Orthotic device (Current Procedural Terminology (CPT) code L8702), 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 is medically stable with no evidence of need for supervision by a physician or in need of acute rehab nursing care. The enrollee may benefit from further physical therapy, but does not require an intensive therapy 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the MyoPro Motion G orthotic device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies have not proven that this device is helpful.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports that the requested MyoPro 2 Motion G orthotic device is medically reasonable and necessary for the enrollee in this case. It is expected to meet, but not exceed the enrollee's medical need, and is expected to be at least as beneficial as existing medically appropriate alternatives. 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 device have been met. Therefore, we decided that the Plan has to pre-approve the MyoPro Motion G orthotic device.
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: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for non-emergency transportation provided on October 13, 2020.

You asked the Plan to pay for non-emergency transportation. You say that this claim should be paid by the
Plan. The Plan denied your request. The Plan says they cannot address this claim until the primary payer sends
an explanation of benefits showing they have addressed the claim. The Qualified Independent Contractor (QIC) overturned the Plans denial stating insufficient information regarding this denial was submitted in the case file. The Plan requested a reopen and provided additional information. The Plan states they have been identified as the Secondary Insurance. The
Plan has identified the primary payer and requested an explanation of benefits from the primary payer. Once
the Plan receives this information from the primary payer, the claim will be reprocessed.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not
responsible for paying for services until the claim for those services has gone to the primary insurer. However,
plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits
with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for
payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can
pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested am
explanation of benefits from the primary payer for review. As the secondary insurer, the Plan cannot be held
responsible for this claim until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for non-emergency transportation services provided on October 13,
2020.