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

We decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided on June 23, 2020, through September 17, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because this code is not durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says this code is not recognized for non-participating providers.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule. CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided on June 23, 2020, through September 17, 2020.
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 LTACH care is medically necessary for continued cardiac monitoring, respiratory therapy, nutrition, renal monitoring, and rehabilitation services.The Plan denied your request. The Plan says the criteria for coverage of LTACH care have 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 documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered 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 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 physician services provided on August 20, 2020 by an out of network provider.You asked the Plan to pay forthe physician services (99358). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe physician services provided on August 20, 2020 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe colonoscopy, flexible, proximal to splenic flexure (45378) provided on September 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe colonoscopy. You say that you have been going to this center to have these procedures for years and you are requesting an appeal.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 colonoscopy, flexible, proximal to splenic flexure (45378) provided on September 10, 2020 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy provided on October 5, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysical therapy. You say that you saw the provider for 30 minutes and was told you didn't need to come back.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 forphysical therapy provided on October 5, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNFservices.You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet medical necessity for a SNF admission based on Medicare coveragecriteria.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 notmedicallynecessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs and her lungs were clear. Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy.There are no identifiable skilled nursing service needs.There are no identifiable skilled therapy service needs.The enrolleedoes not require skilled nursing or therapy services on a daily basis.As a practical matter, the enrolleedoes not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided from September 17, 2020, through September 19, 2020.
You asked the Plan to waive the copayment for the inpatient services. You say that you should not be charged a copayment. The Plan denied your request. The Plan says the copayment was 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 a $492 copayment for each Medicare covered day for days 1-4 of inpatient hospital care. You have been asked to pay a total copayment amount of $984 ($492 x 2 days) for the inpatient services. Inpatient services fall within the Inpatient hospital 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 inpatient services provided from September 17, 2020, through September 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe screening digital breast tomosynthesis (77063) and screening mammography (77067) provided on August 20, 2020.You asked the Plan to pay forthe screening digital breast tomosynthesis and screening mammography. You say that you would like reconsideration because the member had multiple exams on the same date of service.The Plan denied your request. The Plan says the record only supports one unit of the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We find that CPT codes 77063 and 77067 are not supported in the record. Specifically, the submitted documentation only supports one unit of the billed services. The record shows that these codes have already been approved and paid by the Plan. Additionally, per Medicare, CPT codes 77063 and 77067 have an MUE of 1. It is inappropriate to bill these codes more than once per day for the same beneficiary. Based on this information, we decided that Medicare rules for coverage of the screening digital breast tomosynthesis and screening mammography have not been met.
Therefore, we decided that the Plan does not have to pay forthe screening digital breast tomosynthesis (77063) and screening mammography (77067) provided on August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 3, 2020.
You asked the Plan to pay for the ambulance services. 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 on July 3, 2020. 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 provided on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on September 17, 2020
You asked the Plan to pay for the interrogation device evaluation. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim is denied due to the frequency in which it is 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 93298 is Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional. We find that CPT code 93298 is not payable. Specifically, this service was paid for within 30 days prior. Based on this information, we decided that Medicare rules for coverage of the interrogation device evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 1, 2020.You asked the Plan to pay for the physician's services. The Plan deniedyour request. The Plan says prior authorization was not obtained by the provider or facility.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 servicesat 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 physician's services provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe eyeglasses with frame and lenses provided on September 29, 2020.You asked the Plan to waive the cost share forthe eyeglasses with frame and lenses. You say that you should not have to pay out-of-pocket for eyeglasses as you did not have to in 2019.The Plan denied your request. The Plan says the claim has processed correctly based on your supplemental benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $150 allowance.We looked at the file and the Plan's rules. The total cost of the frame and lenses together was $345. You have been charged a coinsurance of $156 which is a smaller amount than what you would be charged with only the $150 allowance. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses with frame and lenses have processed correctly.Therefore, we decided that the Plan does not have to waive the cost share forthe eyeglasses with frame and lenses provided on September 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D9110).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis service is not a covered benefit with the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D9110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D6091, D6010).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese services are not covered by the plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D6091, D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an
IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that you do not require the intensity of services provided at an inpatient rehabilitation
facility. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services
and regular physician evaluation. Your care needs can be met at a lower level of 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea PET scan of the brain.You asked the Planto pre-approvethe scan. You say that thisis medically necessary.The Plandenied your request. The Plansaysthis is not reasonable and necessary under the Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the applicable NCD indicates that a PET/CT of the brain may be covered when a patientmeets diagnostic criteria for both FTD and AD (and other requirements are met). The medical records provided for review did not support that this specific requirement for coverage had been met. Rather, you were not noted to be suspected of having AD or FTD. Rather, the impression was that changes were due to vascular/microvascular ischemic changes. As the requested service is not being used to differentiate between AD and FTD (and other requirements in the NCD were not met) this service would not be 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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea PET scan of the brain
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran occlusal adjustment (D9951) performed on August 10, 2020.You asked the Plan to pay foran occlusal adjustment. You say that you did not ask for this service and were not aware it would not be covered by the Plan.The Plan denied your request. The Plan says rules for payment have not been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay foran occlusal adjustment (D9951) performed on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda(J9045, J9271 and J9201).You asked the Plan to pre-approveKeytruda (J9045, J9271 and J9201). You say that the service is medically necessary.The Plan denied your request. The Plan says there is no evidence these services together are helpful for the treatment of the enrollee's diagnosis.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 Keytruda (J9045, J9271 and J9201). Our reviewer says that the service is notmedically necessary. Our physician reviewer found the service requested is not evidence based and has no support in any compendium or literature for the enrollee's diagnosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda (J9045, J9271 and J9201) have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda (J9045, J9271 and J9201)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvecontinued services. You say that the enrollee cannot go back to her independent living because of her current condition.The Plan denied your request. The Plan says there are no ongoing skilled needs.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.Continued SNF services beyond January 27, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a modified independent to supervision level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.