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

We decided that the Plan has to waive the copayment for wound debridement billed by the physician on February 12, 2021.

You asked the Plan to waive the copayment for wound debridement. You say that this visit was approved, and you do not owe the bill. You say that you do not have the finances to pay and the bill should be taken off your account. The Plan denied your request. The Plan says that the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees pay $0 per visit for all covered physician services.

The Plan says you must pay a $150 copayment for a facility fee for the wound debridement. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the wound debridement. A physician cannot bill an outpatient hospital facility fee. The wound debridement billed by the doctor would be considered a physician service that applies the $0 copayment. Therefore, we decided that the Plan has to waive the copayment for wound debridement billed by the physician on February 12, 2021.

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 that the Plan does not have to pre-approve additional features for a prosthetic leg (L5964, L5920, L5962, L5910).

You asked the Plan to pre-approve the services. You say that standard prosthetic covers would be insufficient. The Plan denied your request. The Plan says the records do not indicate exposure to harsh conditions or engagement in extraordinary activities that require extra protection from a specialized prosthetic cover.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate unusually harsh environmental situations for which a specialized lower limb prosthetic cover (L5962, L5964) would be required, and for which standard covers would be insufficient. The criteria for L5962 and L5964 have not been met. The documentation does not reveal that you are unable to use their current L5910 Alignable System and L5920 Alignable System with the approved replacement socket. 

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 additional features for a prosthetic leg (L5964, L5920, L5962, L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shock treatment and monitoring for the enrollee.

You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's mood was described as relatively positive.

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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has an eating disorder, anxiety, and long-term prescription benzodiazepine use, which are not indications for the requested treatment with electroconvulsive therapy. The enrollee is not showing severity of symptoms which would require treatment. 

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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve shock treatment and monitoring for the enrollee.
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 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. Your 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. You do 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 you do 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from September 12, 2019, through September 20, 2019.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says by
September 12, 2019, clinically the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. He was sent to the emergency room after a resident-to-resident incident. Regarding rehabilitation services, the enrollee received an occupational therapy (OT) evaluation in the SNF. He was able to self-feed and required assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from September 12, 2019, through September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit, the routine venipuncture, and the related services on June 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the wellness visit, the routine venipuncture, and related services. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 the wellness visit, the routine venipuncture, and the related services on June 29, 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 the massage services provided on March 2, 2021.

You asked the Plan to pay for the massage services. You say that you would like these services reimbursed under your Pick Your Perks benefit. The Plan denied your request. The Plan says the services are only covered with a prescription from a licensed and certified practitioner.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. While the Plan does have a supplemental benefit that covers massage for certain indications, the Plan only covers these services when there is a prescription from a licensed and certified practitioner. The documentation did not include a prescription for these services. Therefore, we decided that the Plan does not have to pay for the massage services provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable gaseous oxygen system.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the treating provider has not proven any severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. 

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found supplemental oxygen is not medically necessary. The medical records do not show any oxygen saturation levels below 90%, at rest or with exercise. Medicare criteria are not met, and oxygen would not benefit you medically. 

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable gaseous oxygen system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Evenity (J3111) provided on November 18, 2020.

You asked the Plan to pay for Evenity. You say that there is support for the use of this drug in men. The Plan denied your request. The Plan says this is not payable without a KX modifier.

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 pay for Evenity. Our reviewer says that the use of Evenity is not supported.

Our physician reviewer found the requested use of Evenity is only FDA-approved in postmenopausal women, and the enrollee is a man. The use of Evenity in men is also not supported by one of the major drug compendia or by clinical research that appears in CMS-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pay for Evenity (J3111) provided on November 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, psychotherapy and behavioral assessment provided by an out-of-network provider on October 19, 2020.

You asked the Plan to pay for the office visit, psychotherapy and behavioral assessment. You say that the enrollee recently moved from the west coast and was not aware of the prior authorization requirement. You say that the office was unaware of this policy and in-network benefits should be reconsidered. The Plan denied your request. The Plan says prior authorization was required but 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit, psychotherapy and behavioral assessment provided by an out-of-network provider on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided
February 26, 2021 to March 1, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel the Plan
should cover all the expenses. The Plan denied your request. The Plan says the copayment has been applied
correctly.

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 $325 copayment for each day for days 1-5 each time you are admitted for Medicare-covered
hospital care.

The enrollee has been asked to pay a total of $975 for the inpatient stay ($325 copayment per day x 3 days =
$975). This service falls within the Inpatient Hospital Care 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 copayment for the inpatient hospital stay provided
February 26, 2021 to March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 26, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71046), transportation of portable x-ray equipment (R0070), and the set-up of portable x-ray equipment (Q0092) rendered by the out of network (OON) provider on May 19, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 the chest x-ray (71046), transportation of portable x-ray equipment (R0070), and the set-up of portable x-ray equipment (Q0092) rendered by the out of network (OON) provider on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided March 5, 2021 provided by an out-of-network (OON) provider.

You asked the Plan to pay for the limited oral exam and periapical x-rays.. You say that you were informed the facility was in-network and were not advised that the provider is not in-network. The Plan denied your request. The Plan says the provider who performed the services is not in-network and therefore the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam and periapical x-rays. when the services are rendered by a participating provider.

We looked at the file, and Medicare rules. The requested provider in this case is not a network provider with the Plan. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and periapical x-rays. have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided March 5, 2021 provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services provided on March 1, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management services. You say that you needed medication refill and your new doctor wasn't able to take an appointment. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services provided on March 1, 2021 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the colonoscopy provided the pathology tissue exam provided on August 31, 2020.

You asked the Plan to waive the cost share for the colonoscopy and the pathology tissue exam. You say that you were told a colonoscopy would have a $0 copayment. You say you have had polyps removed in the past and did not pay anything. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulatory surgical center and outpatient hospital visits and 20% for laboratory tests.

You have been asked to pay a $250 copayment for the colonoscopy. You have been asked to pay $23.09 which is 20% of the allowed amount for the pathology tissue exam. The allowed amount is $115.46. ($115.46 x 20% = $23.09). The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The pathology tissue exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows polyps were removed which makes the colonoscopy diagnostic in nature.

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 cost share for the colonoscopy provided the pathology tissue exam provided on August 31, 2020.

Please note, our decision is only regarding the August 31, 2020 date of service. Please contact the Plan directly for any questions regard previous years' billing.