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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says IRF care is not medically necessary.

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. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, 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. Finally,
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.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the 1-month supply allowance for therapeutic continuous glucose monitor (K0553) provided by an out of network (OON) provider.

You asked the Plan to pay for the 1-month supply allowance for therapeutic continuous glucose monitor. You say that the services provided were medically necessary. The Plan denied your request. The Plan says no prior authorization was provided for services rendered by an OON provider.

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 the 1-month supply allowance for therapeutic continuous glucose monitor (K0553) provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges
because you do not recall having the visit. 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). The enrollee's contract with the Plan clearly says that you must pay
a $100 copayment for emergency care.

The medical records show that you received emergency care. Therefore, you are responsible
to pay the $100 copayment.

You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency
care benefit category. This means that you have been asked to pay the correct amount based on the enrollee's
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when the enrollee
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency
care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pacemaker insertion.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had had transient reversible 2:1 Type-1 second degree atrioventricular (AV) block after cardioversion, no syncope, and no recurrent severe bradycardia documented on Holter monitor and is now in persistent atrial flutter. The records therefore do not support the medical necessity of pacemaker placement at this time. Specifically, there is documented non-reversible symptomatic bradycardia due to sinus node dysfunction and no documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve pacemaker insertion.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and R0070).

You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like reconsideration this service was billed with the correct place of service code. The Plan denied your request. The Plan says services provided to member's in a non-covered SNF stay should be reported with place of service code 32.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A Skilled Nursing Facility (SNF) stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, this service was billed with place of service code 31 indicating that the member was in a Part A covered SNF stay. If the member is in a Part A covered stay, the costs for this service are subject to consolidated billing. Additionally, the Plan states that there is no record that the member is in a Part A covered stay. Place of service code 31 is not appropriate for a non-covered stay. Therefore, we decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and R0070).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids you received on June 10, 2020.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says out-of-network
service are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are provided by an in-network provider.

We looked at this the file and the Plan's rules. The hearing aids in question were provided by an out-of-network
provider. The Plan does not cover out-of-network hearing aids. Based on this information, we decided that the
Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not
have to pay for the hearing aids you received on June 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that this service is medically necessary. The Plan denied your request. The Plan says step therapy criteria has not been 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 Prolia. Our reviewer says that the service does not meet step therapy criteria. Our physician reviewer found the Plan requires a trial of zoledronic acid OR a previous history of osteoporotic fracture before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the osteotomy of spine (22207, 22208).

You asked the Plan to pre-approve the osteotomy of spine. You say that this service is medically necessary.
The Plan denied your request. The Plan says medical necessity was not fully established for the requested
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 osteotomy of spine. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the criteria for this very complex multilevel spine surgery is not met. More
conservative measures need to be tried and failed such as a recent course of physical therapy. There is no spinal
instability, fracture, or very severe deformity requiring complex surgery 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 the osteotomy of spine have not been met. Therefore, we decided that the Plan
does not have to pre-approve the osteotomy of spine (22207, 22208).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 15734) provided on May 21, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk". 

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 15734 is not supported by the records provided. Our coding reviewer found that the operative report does not include enough documentation to confirm that a "muscle, myocutaneous, or fasciocutaneous flap" was performed. The report documents a subcutaneous flap, but does not clearly confirm the requested code. 

We looked at this coder'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 pay for the services (CPT 15734) provided on May 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve OON services. You say that the in-network provider is too far. The Plan
denied your request. The Plan says there are in-network options for physical therapy.

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 services at issue in this appeal. We were able to confirm that the Plan has
contract providers located within reasonable distance and travel time from your home who can provide physical
therapy services. We found no exception that would require the Plan to pre-approve these OON services.
Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from being closely monitored. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and do not require transfer.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital with Covid-19 pneumonia and respiratory failure. He appears to be improving, but requires additional short term acute care services for additional weaning which can safely be completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care.

You asked the Plan to waive the copayment for SNF care. You say that you were never billed for any of these charges, and do not feel that you should be held liable for them. The Plan denied your request. The Plan says the copayment amount that you are being charged is correct.

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 per day for days 1 to 20, and a $172 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) Care. This SNF stay lasted 27 days, resulting in a total copayment amount of $1,204.

You have been asked to pay a $0 copayment per day for days 1 to 20, and a $172 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) Care 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 SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the 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 14, 2019. 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 to pay for the services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for genicular nerve destruction (64624).

You asked the Plan to waive the copayment for genicular nerve destruction. You say that you have not been charged for this service in the past. The Plan denied your request. The Plan says this service 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 pay a $275 copayment for each Medicare-covered outpatient surgery.

You have been asked to pay a $275 copayment for genicular nerve destruction, which is considered an outpatient surgery service. 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 genicular nerve destruction (64624).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Gammaplex 10GM/300ML (CPT Code J1557).

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says that the provider requested Gammaplex to treat the enrollee's trigeminal neuralgia and other hereditary and idiopathic neuropathies. The Plan states their physician reviewer determined the drug is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 medication. Our physician reviewer found chronic inflammatory demyelinating polyneuropathy (CIDP; also known as chronic inflammatory demyelinating polyradiculoneuropathy) is an entity that describes a group of related neuropathies, all having chronicity, demyelination, inflammation, and immune mediation in common. For patients who respond well to initial treatment and remain clinically stable, intravenous immune globulin (IVIG) is used as maintenance therapy. Use is supported by the medical literature. The service is reasonable and medically 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 medication have been met. Therefore, we decided that the Plan has to pre-approve Gammaplex 10GM/300ML (CPT Code J1557).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole.

You asked the Plan to pre-approve Pantoprazole. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The 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 Pantoprazole.

Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.