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

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
January 4, 2021 and January 5, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that the enrollee had a 
Moh's surgery on January 4, 2021 and not an office visit. You say the visit on January 15, 2021 should be 
covered under the 90-day post-surgical protocol. The Plan denied your request. The Plan says you have been 
asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for each in-specialist visit. 

The enrollee has been asked to pay an $8.88 copayment, which is less than the standard copayment, on January 
4, 2021 and a $35 copayment for the specialist office visit on January 15, 2021. The specialist office visits fall 
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical 
record shows the visit on January 4, 2021 was for a wound check from the Moh's surgery on November 24, 
2020. Please note, there is no provision in the contract which states a copayment would be waived for a surgery 
follow-up visit.  
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the specialist office visits provided on January 
4, 2021 and January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care (G0151, G0152, and G0299).

You asked the Plan to pre-approve home health care. You say that the services should be covered. The Plan denied your request. The Plan says the services must be obtained from an in-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve home health care (G0151, G0152, and G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the telehealth mental health service and annual depression screening provided March 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to waive the cost share for the telehealth mental health service and annual depression screening. You say that you would like these claims reprocessed. The Plan denied your request. The Plan says these claims processed correctly in this case.

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 50% coinsurance and a $65 copayment for telehealth. 

You have been asked to pay a total cost share of $69.70 for the telehealth mental health service and annual depression screening ($65 copayment plus $4.70 coinsurance). These services fall within the annual depression screening and telehealth outpatient services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the telehealth mental health service and annual depression screening provided March 17, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ankle brace and soft lining for the ankle brace to be
provided by an out of network (OON) provider.

You asked the Plan to pre-approve the ankle brace and soft lining. You say that you would like reconsideration
because you are unable to travel to a network supplier and the requested supplier will come to you. The Plan
denied your request. The Plan says there are network providers available who may supply the requested
equipment.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the ankle brace and soft lining for the ankle brace to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on March 5, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation, and an extraction. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made for the extraction. The limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every year.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and an extraction have not been met. Specifically, the allowed amount of the extraction for an out-of-network provider were paid by the plan. Additionally, the record shows that you had exceeded the frequency limit for a limited oral evaluation prior to this service on February 19, 2021. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on November 25, 2020, to December 1, 2020, by an out of network (OON) provider.

You asked the Plan to pay for SNF services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the 
Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on November 25, 2020, to December 1, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the
requested services are 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing nor skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (for example, home, assisted living, long-term care, hospice). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors.

You asked the Plan to provide therapeutic continuous glucose monitor sensors. You say that the enrollee has difficulty finger stick testing. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a CGM therefore supplies are not covered.

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.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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.

Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an aqua swim fin (L5999).

You asked the Plan to pre-approve an aqua swim fin. You say that you are appealing the denial for an aqua fin
in order to participate in aquatic aerobic exercise and therapy. The fin will allow you to improve blood sugar,
maintain weight reduction, strengthen muscles and control lymphedema. The Plan denied your request. The
Plan says a swim fin does not meet the definition of DME as it is a convenience item useful only for leisure
activities and not appropriate for use in the home.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is a convenience item or is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an aqua swim fin (L5999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow concentrate for a left shoulder arthroscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this service is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that show bone marrow concentrate to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for bone marrow concentrate for a left shoulder arthroscopy 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow concentrate for a left shoulder arthroscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit with in-office procedure provided on 
November 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with in-office procedure. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit with in-office procedure provided 
on November 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of humeral shaft fracture coded 24505 provided on November 4, 2020.

You asked the Plan to pay for the closed treatment of humeral shaft fracture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 24505 is closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction. 

We find that CPT code 24505 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the closed treatment of humeral shaft fracture have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of humeral shaft fracture coded 24505 provided on November 4, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xvega (J0897).

You asked the Plan to pre-approve Xvega (J0897). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not tried and failed intravenous pamidronate or zoledronic acid.

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 Xvega (J0897). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of drug intravenous pamidronate or zoledronic acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Xvega (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Xvega (J0897).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.  

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not 
had a poor response to Retacrit for at least two consecutive months with appropriate dose adjustment.  

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 Aranesp. Our physician reviewer found 
that the enrollee has anemia related to chronic kidney disease. The Plan requires a trial of Retacrit before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no 
documentation provided indicating that the Plan's required drug would likely be less effective or likely have 
adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require daily skilled nursing or therapy services at an inpatient level. 

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 admission have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds of the breast provided on
August 12, 2020.

You asked the Plan to waive the copayments for ultrasounds of the breast. You say that the ultrasound should
be considered preventative and you should not owe anything. 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 $0
copayment for diagnostic mammograms and a $125 copayment for each ultrasound.

You received two ultrasounds of the breast on August 12, 2020. Ultrasounds of the breast are not included in breast cancer screenings. Therefore, you are responsible to pay a $125 copayment per each ultrasound. However, you are only being asked to pay $238.14, which is less than the total copayment amount. 

You have been asked to pay the total allowed amount of $238.14 for ultrasounds of the breast. Ultrasounds of the breast fall 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 copayments for ultrasounds of the breast provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing (95938) and a central motor evoked potential study (95939) performed on November 20, 2020.
You asked the Plan to pay for somatosensory testing and a central motor evoked potential study. You say that your organization alone should be reimbursed for the provided services outsourced by the hospital to you. The Plan denied your request. The Plan says the provided records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a provider furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In this case, medical records verify that the enrollee was inpatient on the date of service. However, the provider reported POS code 15, mobile unit, for the services at issue. Based on this information, we decided that Medicare rules for coverage of somatosensory testing and a central motor evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for somatosensory testing (95938) and a central motor evoked potential study (95939) performed on November 20, 2020