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

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services
You asked the Plan to pre-approve the SNF services. You say that you need to stay longer at the SNF to get the care you need to heal your wound. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found the medical documentation shows that you completed antibiotic IV coverage on January 15, 2020. On January 17, 2020 you were at a minimum assist for transfers with 2 with walker and you had good balance seated and standing. You had no pain. You were independent in bed mobility. You used a 2 wwwalker x 175 feet minimum assist. On 1/20/20, your left wound vac and dressing were in place. Vital signs were stable. Wound vac changes were every week. Surgery was to be rescheduled for your left foot. Our physician reviewer found that 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 beyond what was approved by the health plan. You do not have a tracheostomy tube, enteral feedings, complex daily wound care or other SNF level skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively
provide medically necessary and reasonable treatment in a SNF beyond what was approved by the health plan. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond what was approved by the health plan. 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 pre-approve an admission for skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laparoscopy services coded 43283 provided from August 5, 2019 to August 6, 2019.You asked the Plan to pay forthe laparoscopy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not payable as 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 43283 is Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure).We find that CPT code 43283 is not supported in the medical record. Specifically, these services are not payable on the same day as an inpatient procedure. This service was reported with inpatient procedure coded 43283 for a laparoscopic procedure on the esophagus. This service is not payable when an outpatient payment status indicator is selected/reported unless certain criteria are met, and a modifier CA is attached. Based on this information, we decided that Medicare rules for coverage of the laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay forthe laparoscopy services coded 43283 provided from August 5, 2019 to August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam (J8499).
You asked the Plan to pre-approve Temazepam. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan follows Medicare rules. Medicare 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-approve Temazepam (J8499).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 3, 2019 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says the referring provider is an out-of-network provider. The Plan says that the live in facility is also out-of-network. The Plan says that 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 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 for outpatient lab work provided on September 3, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries
(A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery
Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to
corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips,
lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve the proton beam therapy. You say that proton beam therapy is medically necessary. The Plan denied your request. The Plan says no medical necessity has been established for the request of this treatment.
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 proton beam therapy. Our reviewer says that the documentation does not support that dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods. The documentation does not support that there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates. The documentation does not support that higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary. The documentation does not adequately demonstrate that Proton beam radiotherapy is considered the treatment of choice for this enrollee, and does not address the risk to normal tissue, the risk of disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal Dosimetric, evidence of reduced normal tissue toxicity and/or improved tumor control. Our physician reviewer found no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Knee orthosis (L1833) and suspension sleeve (L2397) provided May 9, 2019.
You asked the Plan to pay for the orthoses. You say that you provided the enrollee with orthotic braces and the records should support medical necessity of the service. The Plan denied your request. The Plan says that a physical examination by the ordering physician is not completed. All of the clinical information is obtained by the provider via telephone interview. It is unknown if the telephonic interview is conducted by a physician or employee of the facility.
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 Knee orthosis (L1833) and suspension sleeve (L2397) provided May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G00463) and laboratory
services (33614, 80076, 80048, 80061, 83036, 85027) provided on September 17, 2019 by an out of network
provider.
You asked the Plan to pay for a hospital outpatient clinic visit and laboratory services. You say that you are
appealing the claim payment denial for services rendered to the Plan's member on date of service September
17, 2019. The service provided was clinically appropriate and medically necessary. The Plan denied your
request. The Plan says the rendering provider is a non-participating provider. The attending provider is a non-participating provider. The Plan did not authorize any services. The services are not considered urgent/emergent in nature.
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 for a hospital outpatient clinic visit (G00463) and
laboratory services (33614, 80076, 80048, 80061, 83036, 85027) provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 13, 2019 to September 1, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 13, 2019 to September 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP device and supplies provided from August 21, 2019 through September 20, 2019.You asked the Plan to waive the coinsurance forthe CPAP device and supplies. You say that you were not informed of a copayment. You say that you should not be responsible.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment from an in-network provider.You have been asked to pay a total of $52.04 for the CPAP device and supplies. Date of ServiceEquipmentAllowed AmountStandard CoinsuranceMember LiabilityAugust 21, 2019Nasal Cushion$36.8020%$7.36August 21, 2019Filter$3.9420%$0.79September 11, 2019Humidifier$13.3020%$2.66September 11, 2019CPAP$39.7520%$7.95September 20, 2019Tubing$35.4620%$7.09September 20, 2019Nasal Cushion$73.6020%$14.72September 20, 2019Nasal Interface$53.3820%$10.68September 20, 2019Filter$3.9420%$0.79TOTAL:$52.04
The CPAP device and suppliesfallwithin 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 coinsurance forthe CPAP device and supplies provided from August 21, 2019 through September 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose (sugar) level (82947), and a hepatitis C antibody test (86803) provided on August 19, 2019 by an out of network provider.
You asked the Plan to pay for blood glucose (sugar) level, and a hepatitis C antibody test. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 19, 2019 as the services were medically reasonable and necessary. The Plan denied your request. The Plan says the doctor is a non-participating provider. The Plan did not authorize any services for this practice or provider. The clinical information received did not establish medical necessity for the requested service. The services are not considered urgent/emergent in nature.
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 for blood glucose (sugar) level (82947), and a hepatitis C antibody test (86803) provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 6, 2019 by out of network provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says theservices 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 involvingemergencies, 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 notpre-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 forthe laboratory services provided on August 6, 2019 by out of networkprovider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a claviculectomy (23120) and rotator cuff
repair (23412) provided on September 21, 2018 and an injection (20610) provided on November 28, 2018.
You asked the Plan to waive the cost-sharing for a claviculectomy, rotator cuff repair, and an injection. You
say that you do not understand what you owe. The Plan denied your request. The Plan says these services
processed 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 pay20%
coinsurance for Medicare-covered surgery services and a $50 copayment for services obtained from a
specialist.
You have been asked to pay $138.93 for a claviculectomy ($694.67 allowed amount x 20% =$138.93), $590.81
for a rotator cuff repair ($2954.05 allowed amount x 20% = $590.81), and $50 for an injection, which is a
service obtained from a specialist. 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-sharing for a claviculectomy
(23120) and rotator cuff repair (23412) provided on September 21, 2018 and an injection (20610) provided on
November 28, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One injections.You asked the Plan to pre-approve these services. You say that you are in a lot of pain.The Plan denied your request. The Plan says the step therapy requirement is not met.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 the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have primary osteoarthritis of both knees. You have not tried and failed the plan's required drugs of orthovisc and monovisc and the records do not show that these drugs would be less effective or have adverse effects. Synvisc One is not reasonable or medically necessary at this time.
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-approveSynvisc One injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital visits provided from February 5, 2019 to March 12, 2019.
You asked the Plan to waive the copayments for outpatient hospital visits. You say that you disagree with the facility charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for non-surgical visits in an outpatient clinic. You received outpatient hospital visits on February 5, 2019 to March 12, 2019 for a total of 3 visits. Therefore, you are responsible to pay the allowed amount of $139.12 per each visit. The total amount you owe is: $417.36. You have been asked to pay the total copayment amount of $417.36 for outpatient hospital visits. Outpatient hospital visits fall within the outpatient hospital services 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 copayments for outpatient hospital visits provided from February 5, 2019 to March 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic testing supplies provided from August 7, 2019 to October 26, 2019.You asked the Plan to pay forthe diabetic testing supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the delivery ticket and proof of delivery are missing required information.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies providedin this case. Review of the file shows that the delivery ticket submitted did not include the carrier's tracking number. Also, the delivery ticket did not include an order number or details to corroborate the delivery ticket submitted. In addition, the proof of delivery is not itemized to indicate the specific supplies provided. Therefore, we decided that the Plan does not have to payforthe diabetic testing supplies provided from August 7, 2019 to October 26, 2019