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

We decided that the Plan does not have to waive the coinsurance for a Prolia injection and administration (96372 and J0897) provided on July 29, 2019.
You asked the Plan to waive the coinsurance for the Prolia. You say that you have had these injections before and the Plan covered the entire cost. The Plan denied your request. The Plan says the service is a covered benefit, but you are responsible for the cost sharing amount assessed by the Plan.
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 Prescription Drugs and a $50 copayment for Outpatient Hospital services.
You were asked to pay $229.25 for Prolia. The allowed amount for this service is $1,146.24. 20% of $1,146.24 is $229.25. The coinsurance for Prolia was assessed correctly.
You have been asked to pay 20% coinsurance for the Prolia and a $50 copayment for administration. the Prolia and administration fall within the Medicare Part B Prescription Drugs and Outpatient Hospital Services benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Prolia injection and administration (96372 and J0897) provided on July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.
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 LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs nighttime BiPAP support, sacral wound care, rectal tube care, surveillance laboratory studies, telemetry monitoring, intravenous cardiovascular infusions as indicated, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion spacer for "the beneficiary".You asked the Plan to pre-approvethese 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 has back pain. The requested Superion spacer is considered experimental/investigational in nature, as more research is needed. The services are therefore not reasonable or medically necessary at this time.We looked atthis 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-approvea Superion spacer for "the beneficiary".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysician services provided on September 5, 2019 to September 6, 2019.You asked the Plan to waive the copayment forphysician services. You say that you were an inpatient.The Plan denied 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 $35 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for physician services. Evidence was provided to show that observation services were provided; therefore, the specialist services that were provided to you have their own copayment.The total amount you are being asked to pay is $70 ($35 x 2 visits = $70).Physician services falls within the physician/practitioner services/specialist visit 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 forphysician services provided on September 5, 2019 to September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on August 6, 2019.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on August 6, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea surgical shoulder arthroscopy (29823, 29826, and 29827).You asked the Plan to pre-approvea surgical shoulder arthroscopy. You say that you need these services due to weakness and pain.The Plan denied your request. The Plan says that this is not medically necessary because you have not failed a three month trial of treatment.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a surgical shoulder arthroscopy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you present with a 6-month history of worsening right shoulder pain status post a fall. You report constant right shoulder pain with prevalent night symptoms and interference in activities of daily living. Clinical exam findings are consistent with imaging evidence of a full thickness retracted rotator cuff tear, rotator cuff tendinosis, and AC joint degenerative changes with impingement morphology. Reasonable and comprehensive long-term conservative treatment, including activity modification, ice, NSAIDs, and home exercise program have been reported without sustained improvement. A recent physical therapy trial is reported with worsening of symptoms. Current evidence based medical literature would support surgical intervention at this time. Additional conservative treatment, including formal physical therapy, is not indicated in the setting of a full thickness retracted tear. Therefore, this request for right shoulder arthroscopic surgery is medically reasonable and 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 a surgical shoulder arthroscopy have been met.Therefore, we decided that the Plan has to pre-approvea surgical shoulder arthroscopy (29823, 29826, and 29827).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe oncology services to be provided by out of network (OON) facility, "the hospital".You asked the Planto pre-approvethe OON oncology services. You say that you have worked at this hospital for many years and believe that they have the best oncology services in the area. You would like the enrollee to be allowed to use this OON provider.The Plandenied your request. The Plansaysthere are numerous network oncology providers able to treat the enrollee. This is a preference for treatment and is not an exception to network restrictions.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who canprovide 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 Plandoes not haveto pre-approvethe oncology services to be provided by out of network (OON) facility, "the hospital".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on wound preparation (15004), exploration of the femoral artery (35721), negative pressure wound therapy (97606), the insertion of tissue expanders (11960), and the incision and drainage of abscess (10060) provided on July 15, 2019.
You asked the Plan to pay for surgical assistant services. You say that surgical assistants can bill these services. The Plan denied your request. The Plan says codes 11960 and 10060 have an Assistant Surgery indicator of "1" which does not allow assistant surgeon payment, and procedure codes 15004, 35721 and 97606 were billed with an inappropriate modifier combination.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an assistant is not medically necessary. We find that CPT codes 15004, 35721 and 97606 are not supported in the medical record. Specifically, they were billed with both modifiers 82 and 58. Modifier 58 should not be reported on assistant surgery services because global surgery rules do not apply to assistants. Services submitted with CPT modifier 80-82 in addition to CPT modifier 58 will be "returned as unprocessable" with remark code MA130. CPT modifier 58 should be removed and the services resubmitted with CPT modifier 80-82. CPT codes 11960 and 10060, have an assistant at surgery indicator of 1. Based on this information, we decided that Medicare rules for coverage of surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on wound preparation (15004), exploration of the femoral artery (35721), negative pressure wound therapy (97606), the insertion of tissue expanders (11960), and the incision and drainage of abscess (10060) provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rexulti for the enrollee.
You asked the Plan to pre-approve Rexulti. You say that the enrollee is not sleeping, eating, or socializing. The Plan denied your request. The Plan says the enrollee's drug coverage is limited to Part B drugs.
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 Rexulti for the enrollee.
Benefits for Rexulti 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forHome Infusion services (S9500 x7) provided May 14, 2019 to May 20, 2019 by "the provider".You asked the Plan to pay forthe home infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says code S9500 has status code "I". The code is not valid for Medicare payment.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 S9500 is not supported in the medical record. Specifically, code S9500 is notvalid for Medicare purposes. A different code is used for payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forHome Infusion services (S9500 x7) provided May 14, 2019 to May 20, 2019 by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond January 10, 2020.You asked the Plan to pre-approvethese services. You say that the enrollee needs more care.The Plan denied your request. The Plan says the continued 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on December 22, 2019 with a displaced fracture of the left tibia. She had stable vital signsand had incontinence. She received physical, occupational, and speech therapy in the SNF and needs assistance with bed mobility and transfers. She needs varied assistance with activities of daily living and is non-weight bearing on the left leg. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not 
have to pre-approvecontinued skilled nursing facility (SNF) services beyond January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental implants and related services.You asked the Planto pre-approvethe dental implant services. You say that the enrollee needs these services due to the injury which damaged her teeth.The Plandenied your request. The Plansaysthis is dental care which is 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 the enrollee's teeth or the structures directly supporting the enrollee's teeth. Although this may have been due to a medical injury, these are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pre-approvedental implants and related services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveSupartz injections (J7321).You asked the Plan to pre-approveSupartz injections. You say that [Enter appellant's argument from appeal letter, the enrollee meets the criteriaThe Plan denied your request. The Plan says the recorddoes not show that the enrollee has failed a 3 month trial of conservative treatment, including the concurrently prescribed physical therapy.The Plan follows Medicare rules. Medicare rules say that hyaluronatepolymer injections are covered only when the patient has a lack of functional improvement following a trial of at least three months of conservative therapy, or the patient is unable to tolerate Non-Steroidal Anti-inflammatory Drug (NSAID) therapy.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 Supartz injections. Our reviewer says that Medicare criteria have not been met. Our physician reviewer found there is no documentation that the enrollee has tried and failed a 3-month trial of conservative treatment, including the concurrently prescribed physical therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz injections have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz injections (J7321)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan (J7321).You asked the Plan to pre-approveHyalgan. You say that the Hyalgan is medically necessary.The Plan denied your request. The Plan says you are required to trial plan preferred drugs first.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 Hyalgan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the plan requires a trial of Orthovisc and Monovisc before alternatives like Hyalgan can be considered. Nothing in the record shows that the plan preferred agents would be ineffective or unsafe for this 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 Hyalgan have not been met.Therefore,we decided that the Plan does not have to pre-approveHyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on July 9, 2019.You asked the Plan to pay forlab tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the sample for this testing was obtained in an office setting, therefore the Place of Service code 81 -indicating an independent laboratory setting -is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of labtests have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Troy Technologies Revo Slim Line Daily Living Wheelchair.You asked the Plan to pre-approvea custom standard manual wheelchair. You say that you struggle to access your bathroom.The Plan denied your request. The Plan says you are able to ambulate short distances with your canes and prosthesis.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 a custom standard manual wheelchair. Our physician reviewer found extenuatingcircumstances arelacking. The enrollee uses a cane and crutches and can apparently ambulate short distances. This specific wheelchair is a convenience item and is not 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 a custom standard manual wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea Troy Technologies Revo Slim Line Daily Living Wheelchair.