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

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on June 26, 2020.
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says Medicare rules for payment of this claim have not been met.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A 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 of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A SNF stay. These services are not separately billable to Medicare Part B when the member is in a Part A SNF stay. Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on June 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate Tab 2.5mg tablet.
You asked the Plan to pre-approve the Methotrexate Tab 2.5mg tablet. The Plan denied your request. The Plan says Methotrexate 2.5mg tablet is considered self-administered and is not covered under the medical benefit. The member does not have a Part D (pharmacy) benefit or a commercial pharmacy benefit with the Plan. You will need to contact the member's pharmacy benefit plan for coverage.
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 Methotrexate Tab 2.5mg tablet.
Benefits for the Methotrexate Tab 2.5mg tablet 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Dupixent.
Benefits for Dupixent 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from September 1, 2020, to December 7, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you are requesting for the plan to waive the copayments. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment per specialist visit. You have been asked to pay a $45 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you made partial payments to the provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits provided from September 1, 2020, to December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the two knee orthoses (L1833 x2) provided on September 23, 2020.
You asked the Plan to pay for the knee orthoses. You say that these items were medically necessary. The Plan denied your request. The Plan says this request is not medically necessary because the records do not support the need or justification for the braces.
The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). 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 pay for the knee orthoses. Our reviewer says that the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. 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 knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the two knee orthoses (L1833 x2) provided on September 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that the enrollee is seeking short-term SNF care before returning home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the unspecified
preventive service (D1999 x 2), and the removal of residual tooth roots (D7520) provided from July 1, 2020, to
July 15, 2020.
You asked the Plan to pay for the limited oral evaluation, the unspecified preventive services, and the removal
of residual tooth roots. You say that you were advised by a plan representative on 2 separate occasions that this
provider was in network. You say that this claim should be covered as in network. You also say that you only
had these services because you were told that the provider was in network. The Plan denied your request. The
Plan says the limited oral evaluation, the unspecified preventive services, and the removal of residual tooth
roots are not listed as covered service. The Plan also says that if you get a service not listed in the table, you
will have to pay the full cost.
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. The Evidence of Coverage clearly states that if you get a service not
listed in the table, you will have to pay the full cost. Therefore, we decided that the Plan does not have to pay
for the limited oral evaluation (D0140), the unspecified preventive service (D1999 x 2), and the removal of
residual tooth roots (D7520) provided from July 1, 2020, to July 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services (97164).

You asked the Plan to pre-approve the physical therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy visits and the records do not demonstrate that the enrollee's functional status needs the ongoing unique skills of a professional therapist. 

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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services (97164).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 10, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 15734 is 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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. We find that CPT code 15734 is not supported in the medical record. Specifically, there is no documentation of a muscle, myocutaneous, or fasciocutaneous flap of the trunk. 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 for the surgical services rendered on September 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Gel-One. Our reviewer says that the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
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 the records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, urinary tract infection and a kidney stone. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 29, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 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 psychotherapy services provided on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate 2.5 MG tablet.
You asked the Plan to pre-approve Methotrexate. 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 Methotrexate 2.5 MG tablet.
Benefits for Methotrexate 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (MPI) rendered on October 13, 2020. You asked the Plan to waive the copayment for these services. You say that the provider told you the services would be covered. 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 $225 copayment per day, per provider for in-network Medicare-covered diagnostic radiology services. Review of the file shows that you received MPI on October 13, 2020. You have been asked to pay a $225 copayment for these services. These services fall within the in-network Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan is not denying coverage for these services. 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 myocardial perfusion imaging (MPI) rendered on October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethason.
You asked the Plan to pre-approve Dexamethason. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Dexamethason.
Benefits for Dexamethason 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services.

You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the cost share.

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 $750 deductible out of pocket before the plan will pay its share for covered medical services.

Review of the file shows that you had advanced imaging services. The records show that your deductible was not met at the time these services were rendered. You have been asked to pay $312.28 to meet your deductible. You have also been asked to pay a $200 copayment for the imaging services after the deductible was met. The services fall within the outpatient 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 cost share for the services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable imaging services provided on October 8, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay.
Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the portable imaging services provided on October 8, 2020.