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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the enrollee has reached the 100-day benefit limit for skilled nursing facility care.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 inpatienthospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from April 25 -October 22, 2019. 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 pre-approveskilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel syringes.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee has been doing well with this medication and had positive results.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveEnbrel syringes.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX (J7321).You asked the Plan to pre-approve Supartz FX. You say that the Supartz FX is medically necessary. The Plandenied your request. The Plan says the documentation does not support medical necessity for a step therapy exception.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 therequest to pre-approve Supartz FX. Our reviewer says that there is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. Our physician reviewer found there is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective 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 Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePrednisone for the enrollee.You asked the Plan to pre-approvePrednisone. You say that this is medically necessary.The Plan denied your request. The Plan says this medication is not covered under Part B.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-approvePrednisone for the enrollee.Benefits for Prednisonemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller with associated hardware for an approve power wheelchair (PWC).You asked the Plan to pre-approvethe expandable PWC controller. You say that it is felt that the requested items are medically necessary.The Plan denied your request. The Plan says the PWC was approve aside from the expandable controller as there is no medical need to control the power components from the main joystick.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 expandable PWC controller. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee carries diagnoses of hereditary spastic paraplegia and chronic pain syndrome, and is wheelchair-dependent for activities of daily living completion, per records. The enrollee has 4/5 upper limb strength. There is no indication that the expandable controller would markedly enhance use/control of the PWC. The device can be safely maneuvered without it and it is considered a convenience item.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 expandable PWC controller have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable controller with associated hardware for an approve power wheelchair (PWC).
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-approveIRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says IRF care exceeds your needs.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images providedon August 26, 2019.You asked the Plan to pay forthe 2D oral/facial photographic images. You say that you called the Plan to inquire about an in-network dentist. You also say that you saw this dentist because you were instructed to by staff members from the plan dental insurance.The Plan denied your request. The Plan says the 2D oral/facial photographic images are not a covered benefit.Medicare generally does not cover dental services. However, thePlan 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe four 2D oral/facial photographic images provided on August 26, 2019.Your complaint about these bills seeming to be fraud is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fornerve conduction studies (95913), needle electromyography (95886 and 95887), and train of four testing (95999) provided on October 29, 2018.You asked the Plan to pay fornerve conduction studies, needle electromyography, and train of four testing. You say that these codes should be paid.The Plan denied your request. The Plan says these codes are not supported by the medical records.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 95913 is nerve conduction studies; 13 or more studies; 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure); 95887 is needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure); and 95999 is unlisted neurological or neuromuscular diagnostic procedure.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 nerve conduction studies, needle electromyography, and train of four testing. Our reviewer says that CPT code 95913 is not supported. The record states that pedicle screws were placed and stimulated. According to CPT rules, this is not considered nerve conduction testing and is reported with a more appropriate CPT code. CPT codes 95886 and 95887 are not supported by the medical record. The record does not contain evidence that needles were placed to perform EMG testing. The record states that pedicle screw and probes were used for triggered EMG testing. According to CPT rules, there is a more specific code for this procedure. Unlisted CPT code 95999 is not supported. The record shows that this code was reported for train of four testing. According to CPT rules, train of four is not a separately reportable procedure and is included in other neuromonitoring procedures.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies, needle electromyography, and train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fornerve conduction studies (95913), needle electromyography (95886 and 95887), and train of four testing (95999) provided on October 29, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF visit provided from May 11, 2019 to June 15, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that you were not aware there would be copayments for the skilled nursing facility care.The Plan denied your request. The Plan says you have been charged 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 $0 copayment for each day for days 1 to 20 at an in-network SNF and a $75 copayment for additional Medicare-covered days, up to 100 days. You have been asked to pay a total of $1,125 copayment for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" benefit category. See chart below.Dates of ServiceServiceCopayment per DaySNF DaysNumber of DaysMember LiabilityMay 11, 2019 to May 30, 2019SNF care$01-2020$0May 31, 2019 to June 15, 2019SNF care$7521-3515$1,125Total$1,125
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 forthe SNF visit provided from May 11, 2019 to June 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit with a dermatologist.You asked the Plan to pre-approve a consultation visit with a dermatologist. You say that this referral had previously been approved.The Plan denied your request. The Plan says there is no medical necessity for this referral.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 consultation visit with a dermatologist. 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 support that a consultation with a dermatologist is medically reasonable and necessary for the enrollee in this case. The documentation regarding the enrollee's family history is not consistent. The Review of Systems does not include any concerns about the enrollee's skin. There is no documentation of any skin lesions on the physical examination.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 consultation visit with a dermatologist have not been met.Therefore, we decided that the Plan does not have to pre-approvea consultation visit with a dermatologis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture.You asked the Plan to pre-approvethe maxillary partial denture. You say that you need partial teeth. You also say that you have to wait two years to get them and that is a really long time.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, partial dentures are limited to one procedure every 5 years. The record shows that you received a partial denture on September 14, 2016 and your partial denture benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe duplex scan provided on December 12, 2018.You asked the Plan to waive the coinsurance forthe duplex scan. You say that there was nothing wrong with your legs and you did not need the scan done. The Plan denied your request. The Plan says you have been charged 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 20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.You have been asked to pay $34.34, which is 20% of the allowed amount of the duplex scan. The allowed amount is $171.71. ($171.71 x 20% = $34.34). The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 forthe duplex scan provided on December 12, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart catheter with coronary angiography (CPT 93458).You asked the Plan to pre-approvethe heart catheter with coronary angiography. You say that you do not understand the denial reason.The Plan denied your request. The Plan says the records do not show that there were moderate or high risk findings on the enrollee's stress test. The plan says that the requested test 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 heart catheter with coronary angiography. Our reviewer says that the requested services are not considered medically reasonable and necessary in thiscase. Our physician reviewer found the enrollee has some coronary risk, atypical chest pain, a normal cardiac physical exam, a normal electrocardiogram and a normal nuclear stress test. Our physician reviewer found that, in this circumstance of atypical pain and an entirely negative noninvasive cardiac evaluation, the post-test likelihood of obstructive coronary disease is low and coronary angiography in this setting is not recommended. Our physician reviewer found that current appropriateness guidelines also do not consider catheterization appropriate in this 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 heart catheter with coronary angiography have not been met.Therefore, we decided that the Plan does not have to pre-approvea heart catheter with coronary angiography (CPT 93458).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvepanniculectomy for the enrollee.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary.The Plan denied your request. The Plan says that to be approved for this procedure, the enrollee must have skin or soft tissue that hangs below the level of the pubic bone, and they must have maintained a stable weight for at least six months.The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation, she has evidence of functional impairment associated with a large overhanging pannus. Her impairment includes chronic dermal irritation (rashes) that has failed typical dermatologic management over a greater than a 3 month period. Photographs and examination detail support that the pannus hangs below the pubis. Her weight from April 2019 to January 2020 support that her weight has been relatively stable.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 surgery have been met.Therefore, we decided that the Plan has to pre-approvepanniculectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on June 18, 2019.You asked the Plan to pay forhospital discharge day management. You say that this should be reprocessed and paid.The Plan denied your request. The Plan says the claim submitted has an invalid diagnosis or condition.The Plan must follow Medicare rules. Medicare rules say that providers must report services and diagnoses correctly. Medicare requires the underlying condition be sequenced first, if applicable, followed by the manifestation.We find that CPT code  is not supported in the medical record. Specifically, this claim was submitted with G92 as the primary diagnosis code. G92 is a manifestation code, making it an invalid primary diagnosis. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay forhospital discharge day management (99239) provided on June 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lisinopril.You asked the Plan to pre-approveLisinopril. You say that the drug being requested is medically necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy with the plan. The Plan says that the enrollee should contact their prescription drug plan.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-approveLisinopril.Benefits for Lisinoprilmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit with a specialist (99213), and aspiration and/or injection of large joint or joint capsule (20610) provided on July 29, 2019 by an out of network provider.You asked the Plan to pay foran office visit and aspiration and/or injection of large joint or joint capsule. You say that the provider is a par provider effective 2014 and to reprocess the claim.The Plan denied your request. The Plan says the services are not authorized because the provider is a non-network provider who does not work with the member's health plan, and the member self-directed for care. The Plansaysthat the member's primary care provider did not refer for services. The Planfurther saysthat the health plan requiresutilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 has network providers available who can provide 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 foran office visit with a specialist (99213), and aspiration and/or injection of large joint or joint capsule (20610) provided on July 29, 2019