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

We decided that the Plan does not have to pay for the assisted living facility visit provided on December 2,
2020 by an out-of-network provider.

You asked the Plan to pay for the assisted living facility visit (99336). You say that the Plan should not
penalize the doctor for the staff's failure in obtaining authorization. The Plan denied your request. The Plan
says the 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the assisted living facility visit provided on December 2, 2020 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at the skilled nursing facility (SNF) provided from January 10, 2021, to February 8, 2021.

You asked the Plan to pay for the continued stay. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have skilled nursing needs. The Plan also says that the SNF care was not medically necessary.

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 continued stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 continued stay have not been met. Specifically, the enrollee did not require any skilled services. Therefore, we decided that the Plan does not have to pay for the continued stay at the skilled nursing facility (SNF) provided from January 10, 2021, to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction; non-surgical access (D3331) provided March 27, 2021.

You asked the Plan to pay for the treatment of root canal obstruction. You say that you received misinformation about the provider's network status and the services should be covered. The Plan denied your request. The Plan says a one-time exception has been allowed for the services from this provider on this date of service to be re-processed as in-network, however this service is not included in your dental 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 the treatment of root canal obstruction; non-surgical access (D3331) provided March 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex interspinous decompression device.

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says Medicare does not cover experimental and investigational services.

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 requested device. Our physician reviewer found that the device remains experimental. High failure rates have been reported with similar items. More research is needed to show the safety and efficacy of the device. Therefore, the requested device is not considered medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex interspinous decompression device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 units of therapeutic exercises (97110) and 2 units of neuromuscular reeducation (97112) provided on July 13, 2020.

You asked the Plan to pay for 3 units of therapeutic exercises (97110) and 2 units of neuromuscular reeducation (97112). The Plan denied your request. The Plan says that the documentation submitted did not support the units 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. 

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 3 units of therapeutic exercises (97110) and 2 units of Neuromuscular reeducation (97112). Our reviewer says that the documentation does not meet criteria. Our physician reviewer found that the ocumentation documents time "Neuromuscular Reeducation CPT 97112 2 units 17 minutes, and Therapeutic Procedure CPT 97110 3 units 32 minutes." Each timed code represents 15 minutes of treatment. Per Medicare rules, in order to bill one unit of a timed CPT code, you must perform the associated modality for at least 8 minutes. CPT 97112 was performed 17 minutes, and therefore 1 unit should be billed. CPT 97110 was performed 32 minutes; therefore, 2 units should be billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 units of therapeutic exercises (97110) and 2 units of neuromuscular reeducation (97112) have not been met. Therefore, we decided that the Plan does not have to pay for 3 units of therapeutic exercises (97110) and 2 units of neuromuscular reeducation (97112) provided on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 2, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer (14301) and a skin graft (15220) provided on September 22, 2020.

You asked the Plan to pay for tissue transfer and a skin graft. You say that these codes are documented. The Plan denied your request. The Plan says the records support one unit of each of these codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that a second unit of CPT code 14301 and of 15220 are not supported in the medical record. The medical record only supports one unit each of CPT code 14301 and 15220, which have been paid. Based on this information, we decided that Medicare rules for coverage of tissue transfer and a skin graft have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer (14301) and a skin graft (15220) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult with a tertiary provider.

You asked the Plan to pre-approve tertiary care. The Plan denied your request. The Plan says there is no medical necessity for this request.

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 tertiary care. Our physician reviewer found that the records do not show that your care requires highly specialized providers, or that your care cannot be well-managed by a community specialist. Your medical condition is not considered complex. A tertiary level of care is 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 tertiary care have not been met. Therefore, we decided that the Plan does not have to pre-approve a consult with a tertiary provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from January 7, 2021, through January 8, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee had returned to his prior level of function and did not have skilled nursing needs.

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 based on the documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee had reached a plateau in function. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 7, 2021, through January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says BiPAP settings are being used for treatment on the ventilator machine, therefore a BiPAP device can provide the same support for home use, and the home ventilator is not medically 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 home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found that the settings required for the ventilator can be provided with certain BiPAP devices. Medicare does not cover a home ventilator when used as BiPAP. 

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the oral appliance provided on July 14, 2020.

You asked the Plan to pay for the oral appliance. You say that the claim was incorrectly denied. The Plan denied your request.
The Plan follows Medicare rules. Medicare rules say that oral appliances are only covered under certain medical indications. 

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 oral appliance. Our physician reviewer found that in this case, the record indicates the enrollee has sleep apnea and was seen in a face-to-face visit by a sleep medicine specialist. The device was ordered after the test and provided by a licensed dentist. The AHI was 39. The elements of the coverage rules were satisfied. 

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 oral appliance have been met. Therefore, we decided that the Plan has to pay for the oral appliance provided on July 14, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the automatic external defibrillator, with integrated electrocardiogram analysis (K0606) provided January 31, 2021.

You asked the Plan to waive the copayment for the automatic external defibrillator. You say that you were told at the time that Medicare would pay for it and was under the assumption that the cost would be taken care of and you would not have to worry about being charged for it. The Plan denied your request. The Plan says this claim was processed with the correct cost share was applied per the Evidence of Coverage.

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% of the plan allowed amount for Medicare covered durable medical equipment for Durable medical equipment (DME) and related supplies.

You have been asked to pay $614.38 for the automatic external defibrillator. The automatic external defibrillator falls within the Durable medical equipment (DME) and related 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 automatic external defibrillator, with integrated electrocardiogram analysis (K0606) provided January 31, 2021.
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 of an individual (CPT code 99397) provided on December 7, 2020.

You asked the Plan to pay for the services. You say that the accounting staff who is resisting changing codes for services provided as this is the code the office has billed for the years you have been getting an annual check-up. You state since your primary physician has already been paid for your annual physical exam, it appears that you, the patient is left no recourse but pay the bill to preserve your credit record and your relationship with the doctor. The Plan denied your request. The Plan says you had a similar evaluation done on November 25, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you had a periodic comprehensive preventive medicine reevaluation and management of an individual (CPT code 99397) on November 25, 2020, by a different provider. You then had the same exam performed on December 7, 2020. Your 2020 EOC states that you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every twelve (12) months. 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 pay for the periodic comprehensive preventive medicine reevaluation and management of an individual (CPT code 99397) provided on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve
(L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items are medically
necessary. The Plan denied your request. The Plan says the request does not meet Medicare criteria for DME.

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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 20, 2020 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 referring provider 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 December 20, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coolief genicular nerve radiofrequency ablation procedure.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the clinical effectiveness of the procedure in the setting of degenerative joint disease of the knee has not been demonstrated in peer-reviewed literature.

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 requested services. Our physician reviewer found that the enrollee has bilateral knee pain. She has tried steroid injection, viscosupplementation, physical therapy, and is taking Hydrocodone and Ibuprofen for pain. Cooled radiofrequency ablation is considered experimental. Radiofrequency ablation of the genicular nerves is still considered experimental/ investigational with ongoing clinical trials to determine its role in the management of osteoarthritis of the knee. Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coolief genicular nerve radiofrequency ablation procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on August 5, 2020.

You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says that the Plan has insufficient documentation to corroborate the services to confirm if Medicare coverage has been met.

The Plan must follow Medicare rules. Medicare rules say that the provider 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 file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on August 5, 2020.