Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on April 4, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have topay forthe services provided on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe debridement services rendered on March 3, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 11042 and 11045 are not supported.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 11042 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. The definition of code 11045 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).We find that CPT codes 10042 and 11045 are not supported in the medical record. Specifically, there is no documentataion of debridement of subcutaneous tissue of the first 20 sq cm or less to support code 11042. Given that the primary procedure code 11042 is not supported, add-on code 11045 is also not supported.. 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 pay forthe debridement services rendered on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like reconsideration
because you have dementia and cannot get out of bed without assistance. The Plan denied your request. The
Plan says the records do not show that you require frequent changes in body position and/or have an immediate
need to change body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 semi-electric hospital bed. Our
reviewer says that the documentation does not clearly reveal that your condition has failed positioning of the
bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. Our
physician reviewer found the documentation does not support a need for an immediate change in body position
or special attachments that cannot be fixed on an ordinary bed.
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 semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on March 24, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician 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.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 forphysician services provided on March 24, 2020, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on August 27, 2020, by out-of-network providers.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says the providers are out-of-network, the services were not referred by a network provider and the services were 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 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 forthe medical services provided to the enrollee on August 27, 2020, by out-of-network providers.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the addition of nivolumab to the current encorafenib and
panitumumab regimen.
You asked the Plan to pre-approve the use of nivolumab. You say that it is felt that it is possible that adding
nivolumab could help improve his quality of life status. The Plan denied your request. The Plan says this is
currently experimental and not supported by the compendia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 use of nivolumab. Our reviewer
says that the requested addition of nivolumab is not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has metastatic colon cancer with is MSI stable. The current regimen
is having a mixed response favoring progression. The enrollee has a poor quality of life score and is
symptomatic. There is an ongoing trial for this regimen for patients with MSI stable disease. However, at this
time, this treatment is not FDA-approved and not supported by the compendia. The ongoing study does not yet
have results to support this regimen.
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 use of nivolumab have not been met. Therefore, we decided that the Plan
does not have to pre-approve the addition of nivolumab to the current encorafenib and panitumumab regimen.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider on August 26, 2020.You asked the Plan to waive the copayment for an ECG. You say that you do not agree with this copayment. The Plandenied your request. The Plan says the correct copayment 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 $25 copayment for outpatient diagnostic tests/diagnostic tests. You have been asked to pay a $25 copayment for an ECG. An ECG falls within the outpatient diagnostic tests/diagnostic tests 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 an ECG provided by a participating provider on August 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy with RST neoGen-Series combined with subcutaneous Nutri-pharmaceutical blend injections provided from October 6, 2020, through October 29, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not medically necessary. The Plan states this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for therapy with RST neoGen-Series combined with subcutaneous Nutri-pharmaceutical blend injections provided from October 6, 2020, through October 29, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an interlaminar lumbar/sacral epidural injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says that the enrollee is no longer eligible for coverage with this plan.
The Plan must follow Medicare rules. Medicare rules say that epidural injections are generally performed to
treat pain arising from spinal nerve roots.
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 injection. Our reviewer says that the
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee failed conservative therapy and had greater than 50% pain relief on prior injections. The
request meets all of the criteria for an epidural injection. The coding is for a single level. The request is
medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. The plan's 
denial reason is invalid, as the request for injection was made while the enrollee was still eligible with the plan. 
Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, 
we decided that the Plan has to pre-approve an interlaminar lumbar/sacral epidural injection for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar spine surgery. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care provided from January 29, 2021, forward.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission, you not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 29, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors or any symptoms which would require acute treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care provided from January 29, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for arthrocentesis, aspiration and/or injection (20611) hyaluronan or derivative, orthovisc, for intra-articular injection, per dose (J7324) provided.

You asked the Plan to waive the co payment for the outpatient diagnostic services. You say that none of these injections worked. You are still in pain. This is going to be costly if you cannot find a resolution to help with the pain.The Plan denied your request. The Plan says this claims were processed correctly 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% coinsurance for Medicare Part B covered drugs and $40 diagnostic procedure and tests for Medicare Part B prescription drugs and Outpatient hospital services. 

You have been asked to pay $110 for the outpatient diagnostic services. the outpatient diagnostic services fall within the Medicare Part B prescription drugs and 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 co payment for arthrocentesis, aspiration and/or injection (20611) hyaluronan or derivative, orthovisc, for intra-articular injection, per dose (J7324) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services (G0491) provided.

You asked the Plan to waive the coinsurance for dialysis services. You say that a representative of the Plan told the dialysis provider that the copayment should be $5.The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for outpatient dialysis.

You have been asked to pay $45, or less than 20% of the Medicare-allowed amount of $330, for each instance of dialysis services. Dialysis services fall within the "Services to treat kidney disease" benefit category. This means that you have been asked to pay less than or equal to 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 coinsurancefordialysis services (G0491) provided.

Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forimmunizations provided on September 4, 2020.You asked the Plan topay forimmunizations under Medicare Part B. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says immunizations are not covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunizations under Medicare Part B. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to immunizations under Medicare Part B.Therefore,we decided that the Plan does not have to pay forimmunizations provided on September 4, 2020.Benefits for immunizations may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration (90471) zoster shingles vaccine 
(90750) provided August 21, 2020. 
 
You asked the Plan to pay for shingles vaccine. You say that when you went to the pharmacy, you handed them 
your insurance card and they did not say anything about it being covered or not. You assumed this was covered 
since the pharmacist did not say anything. The Plan denied your request. The Plan says this service is not 
covered under the plan benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine. 
Therefore, we decided that the Plan does not have to pay for immunization administration (90471) zoster 
shingles vaccine (90750) provided August 21, 2020.  
 
Benefits for shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 1, 2020 to March 1, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the type of 
bill is inconsistent with the place of service. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from February 1, 2020 to March 1, 2020.