Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says guidelines for coverage of SNF care have not been met. The enrollee can receive the care needed in another setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 are at very high risk of infection and need to be closely monitored. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor at least 3 times a week or an intensive team for 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 the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 Perjeta injection (J9306) and Herceptin injection (J9355).
You asked the Plan to pre-approve the injections. You say that you do not want the enrollee's condition to suffer of a metastasis or grown more malignant cell or protein. You also say that this is medically necessary. The Plan denied your request. The Plan says the provided documentation does not support the safety or efficacy of the requested drugs. The Plan also says that the requested drugs are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the injections. Our reviewer says that the requested drugs, Herceptin and Perjeta, are not medically necessary. Our physician reviewer found the request is for use of Herceptin and Perjeta without chemotherapy. Herceptin and Perjeta are not supported by Medicare approved compendia without chemotherapy. Therefore, the reviewer found that the requested drugs are not 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Perjeta injection (J9306) and Herceptin injection (J9355).
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met 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 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 does require physical therapy and occupational therapy services but based on the medical records provided does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 a drug test provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99337) provided on March 26, 2021, by an out of network (OON) provider.
You asked the Plan to pay for a rest home visit. You say that the assisted living facility is responsible to obtain prior authorization for the member. 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 rest home visit (99337) provided on March 26, 2021, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with a ReActiv8 restorative neurostimulator (64555, 64590).
You asked the Plan to pre-approve a ReActiv8 restorative neurostimulator. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/investigational.
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 a ReActiv8 restorative neurostimulator. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is insufficient evidence to demonstrate that the ReActiv8 restorative neurostimulator is a useful and effective treatment modality 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 a ReActiv8 restorative neurostimulator have not been met. Therefore, we
decided that the Plan does not have to pre-approve treatment with a ReActiv8 restorative neurostimulator (64555, 64590).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use other than knee (E0936).

You asked the Plan to pre-approve the CPM device. You say that you are requesting an appeal for the denial of the therapy chair. Your surgery is scheduled on 5/20/2021 and the chair was to be delivered on Monday 05/16/2021. The Plan denied your request. The Plan says the request for coverage for a continuous passive motion machine for the shoulder does not meet the Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use other than knee (E0936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee needs the requested ventilator for respiratory support and that a BIPAP is not sufficient for the enrollee and her ongoing diagnosis. You say that this life saving device will allow the enrollee the ability to maintain activities of daily living and decrease the frequency of exacerbations and hospitalizations. The Plan denied your request. The Plan says the requested ventilator will be sued to provide CPAP or bi-level CPAP therapy and is therefore not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has chronic obstructive pulmonary disease and respiratory failure. The record indicates that AVAPS-
AE settings with a target tidal volume of 550 EPAP 7 and PS 20 are requested. A trial of an E0471 device has not been performed. The plan has covered BIPAP devices that can deliver AVAPS setting. The medical necessity and reasonableness, as defined by Medicare rules, is not supported by the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260), guided tissue regeneration (D4266), sinus augmentation (D7952) and surgical tooth extraction (D7210).
You asked the Plan to pre-approve the dental services. You say that you do not understand this denial and are dissatisfied with your benefits. The Plan denied your request. The Plan says the requested services are purely dental in nature. They are unrelated to the limited clinical indications that may be covered by Medicare. These services are not eligible for coverage under the medical benefit, nor are they covered by the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. The records indicate that these services are dental in nature and are not requested as eligible Medicare-covered services. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4260), guided tissue regeneration (D4266), sinus augmentation (D7952) and surgical tooth extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 24, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you feel the services do not warrant a copayment. 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 $30 copayment for specialist visits. 

You have been asked to pay a $30 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 December 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is experimental and investigational.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental; more research is needed to show safety and efficacy. 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 Vertiflex device have not been met. Specifically, there is not enough information on the safety and efficacy of this device making it experimental. This means the item is not
medically necessary. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eleven tooth extractions (D7140) provided on March 15, 2021.
You asked the Plan to pay for the extractions. You say that you thought you could see this dentist and did not realize that this provider did not participate with Medicare. The Plan denied your request. The Plan says services rendered by providers who have opted-out of Medicare participation are not covered. This provider was not participating with Original Medicare on the date in question.
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 can cover eligible dental services when they are provided by a licensed dental provider who has not opted out of Original Medicare. We were able to confirm that the provider in this case does not participate with Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, services received from an opt-out provider are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for eleven tooth extractions (D7140) provided on March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 8, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed that you would owe anything for the services. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on October 8, 2020. The total allowed amount is $268.77 and 20% of that is $53.75. 

You have been asked to pay the total coinsurance amount of $53.75 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), fillings (D2160 x3), and re-cement or re-bond of a crown (D2920) provided from September 14, 2020, through September 23, 2020.

You asked the Plan to pay for an intraoral periapical radiographic image, fillings, and re-cement or re-bond of a crown. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 an intraoral periapical radiographic image (D0220), fillings (D2160 x3), and re-cement or re-bond of a crown (D2920) provided from September 14, 2020, through September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on September
3, 2020 and billed under code 99199.
You asked the Plan to pay these services. You say that this claim should be paid. The Plan denied your request.
The Plan says while a portion of this claim was paid, code 99199 was billed in error based on the type of
practitioner rendering the services. The Plan states per Medicare billing guidelines, anesthesia services must be
billed with 00100-01999 when billed by an anesthesia practitioner.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case code 99199 cannot be paid as billed due
to the type of practitioner listed as having provided the service.
Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for practitioner
services provided to the enrollee on September 3, 2020 and billed under code 99199.