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

We decided that the Plan does not have to pay for home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided December 10, 2020 to December 31, 2020.
You asked the Plan to pay for the home health services. You say that the enrollee was released from the hospital and you were unable to find a rehab facility that would take her to finish her recovery. The enrollee needed 24/7 care, so you arranged for treatment and recovery at home. The Plan denied your request. The Plan says this provider was not a Medicare certified provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided December 10, 2020 to December 31, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the drugs (J8530) provided from July 14, 2020, to September 9, 2020.

You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says that the services were billed without the appropriate modifier.

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. The Plan argues that Local Coverage Article (LCA) A52474 requires the -KX modifier to be appended to the requested drug code when billed by a durable medical equipment (DME) supplier or pharmacy. However, the referenced LCA does not indicate that the -KX modifier is required in this situation. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the drugs (J8530) provided from July 14, 2020, to September 9, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules 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. We looked at the file and Medicare rules. The documentation shows that the services in question were 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 the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on December 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gimoti (J3490).

You asked the Plan to pre-approve Gimoti. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.

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 Gimoti (J3490).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 30, 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 the services are 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 11642 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm. We find that CPT code 11642 is not supported in the medical record. Specifically, there is no documentation of the size of the excised diameter. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid.
In this case, the MUE for CPT code 15823 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the surgical services rendered on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on April 19, 2021.
You asked the Plan to pay for the periodic oral evaluation. You say that you would like to appeal this service. The Plan denied your request. The Plan says this procedure is not included in the benefits section of your EOC and is 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR testing rendered on February 18, 2021.

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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 

We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care for the diagnosis and treatment of a UTI. 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 pay for the Urine PCR testing rendered on February 18, 2021.
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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. 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 waive the copayment for the inpatient care provided from March 16, 
2021, to March 19, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford to pay this 
bill and were told it would be covered by the Plan. The Plan denied your request. The Plan says the total 
$885.00 copayment applied correctly. The Plan also says that cost sharing is a contractual obligation under the 
Plan and cannot be waived. 
 
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 $295 
copayment each day for days 1 to 6 each time you are admitted for Inpatient Mental Health Care. You have been asked to pay a $295 copayment each day for days 1 to 6 for the inpatient care. The inpatient 
care falls within the Inpatient Mental Health 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 the inpatient care provided from March 16, 2021, to March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the lower right quadrant and pontics for teeth #5 to 13 for a fixed bridge.
You asked the Plan to pre-approve periodontal scaling and root planing in the lower right quadrant and pontics for a fixed bridge. You say that you need the services because you have calcium deficiency that is causing your teeth to suffer, and your upper gum is retracting. The Plan denied your request. The Plan says the services are not medically necessary.
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. The Plan covers periodontal scaling and root planing for the lower right quadrant and pontics for a fixed bridge when the services are medically necessary and reasonable. 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 periodontal scaling and root planing in the lower right quadrant and pontics for a fixed bridge. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that scaling and root planing (D4341) includes four or more teeth per quadrant but only three teeth are present in the lower right quadrant. Our reviewer says that the correct code was not requested. Our reviewer says that the criteria for a fixed bridge is for the replacement of a single maxillary anterior tooth when there are no missing posterior teeth. Our reviewer found that this replacement involves multiple maxillary teeth with multiple missing posterior teeth. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing for the lower right quadrant and pontics for a fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in the lower right quadrant and pontics for teeth #5 to 13 for a fixed bridge.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 
1, 2021.  
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are 
not covered by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation.  
We looked at the file and the rules. In this case, there are insufficient medical records to show that the use of 
the testing will be used to assist in the management and/or treatment of the enrollee. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve the spinal cord stimulator. You say that the enrollee is in a severe amount of pain. You say that the requested device can alleviate the pain and improve the enrollee's quality of life. The Plan denied your request. The Plan says the requested device is 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 the spinal cord stimulator. Our reviewer says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. There is no evidence that the enrollee has had spinal surgery or a spinal injury. The enrollee has had physical therapy and is doing home exercises. She takes Duloxetine, Gabapentin, Hydrocodone/Tylenol, Ketorolac and Lidocaine patches for pain. The enrollee has a psychiatric clearance for a spinal cord stimulator trial. She is status post radiofrequency ablation of the facet joints L2-L5, as well as sacroiliac joint injections and epidural steroid injections. There are no surgical, physical medicine and rehabilitation, or other multi-disciplinary consults. The enrollee does not have an indication that makes the spinal cord stimulator medically reasonable and 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 the spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 2, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 2, 2021, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 5, 2021, to February 3, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 13, 2020, to January 4, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 5, 2021, to February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says back pain by itself does not meet medical coverage for chiropractic care. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules say that Medicare does not cover 
chiropractic maintenance care. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found x-rays of the 
lumbar spine demonstrated mild scoliosis, diffuse degenerative changes, caudal facet arthropathy, and 
osteopenia without fracture. The documentation does not support that the enrollee has subluxation of the spine 
demonstrated by x-ray or physician's exam. The requested referral does not provide a significant and 
reasonable expectation of recovery or improvement of function. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) provided on April 1, 2021.
You asked the Plan to waive the copayment for an outpatient procedure. You say that you thought this was a routine procedure. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $290 copayment for each Medicare-covered ambulatory surgical center visit and outpatient hospital facility visit.
You have been asked to pay a $290 copayment for an outpatient procedure. The records show that you received services in an ambulatory surgical center. The EOC confirms $290 is the required copayment for this service. 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 an esophagogastroduodenoscopy (43239) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical procedure to repair an initial inguinal hernia (49505) provided on May 4, 2021.

You asked the Plan to pay for a surgical procedure. You say that the underlying focus of obtaining an authorization is to assure the insurance carrier that the services provided are medically necessary. You also say that this is the case in this situation. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a surgical procedure to repair an initial inguinal hernia (49505) provided on May 4, 2021.