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

We decided that the Plan does not have to pay for skilled nursing services provided on September 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. 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 skilled nursing services provided on September 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a standard wheelchair provided on
November 16, 2020.

You asked the Plan to reimburse you for the standard wheelchair. You say that you contacted three providers and the first provider did not take your insurance and the other two providers did not have any wheelchairs available. The Plan denied your request. The Plan says you must use a provider that is participating with Medicare and in-network with your Plan.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 

We looked at the file and Medicare rules. You purchased the standard wheelchair from an online company that is not a provider or a supplier that is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for a standard wheelchair provided on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on August 11, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not
covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab services billed on this claim. Without a documented lab order, it cannot be
determined whether this testing was ordered for covered purposes. Based on this information, we decided that
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not
have to pay for genetic testing provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Medicare rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The provider has written a letter which indicates that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. However, the record did not include any relevant medical records to corroborate the testimony of the provider. Without these medical records, we cannot verify that the enrollee meets the relevant Medicare criteria for the therapeutic continuous glucose monitor.

Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on November 11, 2020.

You asked the Plan to pay for the dental items. You say that you have a progressive disability which results in trouble understanding what you hear or read. You say that you know that your disability impacted your understanding and resulting choices. You also say that your tried to get assistance. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that services that you receive out of network 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as a covered service, services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve liquid nutrition.

You asked the Plan to pre-approve liquid nutrition. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. 

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 liquid nutrition. Our reviewer says that the requested liquid nutrition is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a female with diabetes who is able to tolerate food by mouth and is being requested Glucerna drinks. The criteria for tube feeds are not met as she does not have any gastrostomy or other dysfunction in the gastrointestinal track to support liquid nutrition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of liquid nutrition have not been met. Therefore, we decided that the Plan does not have to pre-approve liquid nutrition.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 19, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 physician's services provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on November 27, 2020.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 ophthalmological services provided on November 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have left knee pain from osteoarthritis that has been confirmed on imaging studies. There is severe bone-on-bone arthritis and prior failure of viscosupplementation therapy. The records do not support that Durolane would be safe and effective or medically necessary, given the prior failure of this treatment in the past. 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 Durolane.
Local Coverage Determination (LCD) L35427 referenced by the Plan is not binding for this state and was not used in this determination.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says that rules for SNF care have 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 SNF care is medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is an 85-year-old female who has documented skilled therapy and skilled nursing needs. The enrollee is functioning below her baseline and has not yet been shown to have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 28, 2020.
You asked the Plan to waive the copayment for the ultrasound. You submitted your bill for review. You say that you are trying to figure out why this wasn't covered. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $115 copayment for each Medicare-covered radiological diagnostic service from an in-network provider. You have been asked to pay a $115 copayment for the ultrasound.
The ultrasound 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 copayment for the ultrasound provided on October 28, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve food thickener.

You asked the Plan to pre-approve the item. You say that there are issues with swallowing. The Plan denied your request. The Plan says there are no supporting clinical records to show the need for this request.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve food thickener.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that the enrollee is a 70-year-old male who was admitted to an acute care hospital. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99292) provided to the enrollee from March 13, 2020 to May 4, 2020.
You asked the Plan to pay for the services. You say that there was no choice but to use an out-of-network provider. The Plan denied your request. The Plan says CPT 99292 was incorrectly billed due to no primary code billed.
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 99292 is "Critical care, evaluation, and management of the critically ill or critically injured patient; each additional list 30 minutes separately in addition to code for primary service." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the request is for payment of additional critical care time. The medical record does not indicate that the requesting provider or anyone in his billing group provided initial critical care services. 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
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Afirma Thyroid Fna Analysis.
You asked the Plan to pre-approve Afirma Thyroid Fna Analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Afirma Thyroid Fna Analysis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multinodular goiter. There is no evidence to support that the requested service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). Therefore, the enrollee does not meet criteria for the requested services. Review of the file shows that the Plan uses Local Coverage Determination (LCD) L35160 and Local Coverage Article (LCA) A54356 to support their denial. However, this LCD and LCA are not valid for the enrollee's home state. Therefore, we cannot use the LCD and LCA to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Afirma Thyroid Fna Analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Afirma Thyroid Fna Analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) provided on
January 5, 2021.

You asked the Plan to pay for the dental service. You say that you have spoken with your provider who has
agreed they will not charge you for the exam. You also say that you would like to be on the safe side and file an
appeal in case it is something they try and bill you for. The Plan denied your request. The Plan says it is not
listed as a covered service. The Plan also says that comprehensive periodontal exam is not considered a
preventive service.

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 is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
comprehensive periodontal exam (D0180) provided on January 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for autonomic nervous system function testing (95924) provided on October 14, 2020.

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 95924 is testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt.

We find that CPT code 95924 is not supported in the medical record. Specifically, the time spent on passive tilt is not documented. Based on this information, we decided that Medicare rules for coverage of autonomic nervous system function testing have not been met. Therefore, we decided that the Plan does not have to pay for autonomic nervous system function testing (95924) provided on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance of the allowed amount for an injection provided by Coastal Cardiology on June 10, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $237.48. The total amount you are being asked to pay is $47.50 ($237.48 x 20% = $47.50). An injection falls 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 an injection provided by Coastal Cardiology on June 10, 2020.