Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health skilled nursing and aide services.

You asked the Plan to pre-approve the continued home health care. You say that you are not able to care for the enrollee as well as he needs due to your own health issues and his height/weight compared to yours. He requires home health care to deal with his daily living activities. The Plan denied your request. The Plan says the enrollee does not need the skills of a trained nurse to manage his medical conditions.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 continued home health care. Our reviewer says that the documentation does not support the medical necessity of the requested services. Our physician reviewer found the member is a 40-year-old male with a medical history including multiple sclerosis with hemiplegia who requires assistance with self-care tasks. There is no indication that the member has a feeding tube, parenteral medications or complex wound care issues. There is no indication that the member had any recent medication changes or hospitalizations. There has not been a recent decline in function and the member has been medically stable.

In this case, the documentation does not support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested additional home health services are 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 the continued home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health skilled nursing and aide services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you did not receive proper notice of the enrollee's benefit determination which resulted in the untimely submission of the claim. The Plan denied your request. The Plan says the original claim has a processed date and this corrected claim was received. The Plan also says that this is past the allowed 12 month time frame.

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 subsequent nursing facility care was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered.

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 99213 is not separately payable.

The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every HCPCS code. 

We looked at the file and Medicare rules. The provider billed procedure code 99213 (office visit). This code has a status indicator of B under the outpatient payment system and is not separately payable. Therefore, we decided that the Plan does not have to pay for the office visit rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered.

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 99239 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 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections.

You asked the Plan to pre-approve the Supartz FX injections. You say that it is felt that the requested drug is medically required. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.

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 the Supartz FX injections. Our reviewer says that the documentation does not support that this drug is medically necessary based on step therapy criteria. Our physician reviewer found the enrollee is a male with pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. He has failed conservative treatment. There is no evidence that the preferred drug Orthovisc has been tried/failed. Based on the medical records provided, there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient.

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 Supartz FX injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92012) provided by an out of network (OON) provider.

You asked the Plan to pay for the eye exam. You say that the enrollee was residing in a nursing home setting at the time the services were provided and did not have the opportunity to choose an in-network provider. The Plan denied your request. The Plan says they only cover out-of-network care in limited circumstances. The services provided were not urgent or pre-approved. It is the responsibility of the provider or facility to verify eligibility and obtain 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 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 for the eye exam (92012) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or rendered in a participating 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 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 for physician services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210).

You asked the Plan to pay for the dental services. You say that you do not recall getting these services in the year 2020. You say that you are entitled to two annually. You also say that the dentist checked with your plan prior to the visit to ensure you were covered. The Plan denied your request. The Plan says 1 comprehensive or periodontic oral evaluation is covered every 3 years. The Plan says that 1 complete series x-ray or panoramic film is covered every 5 years. The Plan also says that the frequency limits for these services have been exceeded.

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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and a complete series x-ray. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department (ED) services billed with code 99284.

You asked the Plan to pay for the ED services as billed. You say that this was billed correctly and should be paid as billed. The Plan denied your request. The Plan says payment was downgraded to code 99282 which is more appropriate to describe the level of service rendered.

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 99284 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.

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 ED services as billed. Our reviewer says that the documentation does not support the use of code 99284 for this visit. Our coding reviewer found the medical records provided do not meet requirements described in Code definition to meet this level of service; therefore, it is not appropriate to bill 99284 for the service.

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 ED services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) services billed with code 99284.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered.

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 the claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450/UB-04 hard copy form.

We looked at the file and Medicare rules. The file shows that the claims were not billed on the required CMS-1450/UB-04 form. Therefore, we decided that the Plan does not have to pay for the home health services rendered.

Benefits for these services 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF care. You say that it is felt that Medicare payment should be made for these dates. The Plan denied your request. The Plan says Medicare Part A criteria for coverage were not met on these dates.

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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found from a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her oral intake was 25-50% and improving. She was treated for pain with effect. Her lungs were clear. The beneficiary required assist of two for transfers or a mechanical lift for the dates in question.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting on the dates in question.

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 care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the plan requires the utilization of in-network providers unless the Plan pre-approves out-of-network services in non-emergent situations. The provider did not make attempts to verify the member's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services.

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 subsequent nursing facility care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 for physician services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs and to pay for the self-administered drugs.

You asked the Plan to waive the coinsurance for the Part B drugs and to pay for the self-administered drugs. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B drugs on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan. The Plan also says that the self-administered drug provided is not covered under your Medicare Part B benefit. The self-administered drug may be covered under your Medicare Part D benefit.

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 20% coinsurance for Medicare Part B prescription drugs.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B drugs. You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $949.53. The Part B drugs falls within the Medicare Part B prescription drugs 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.

The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided here are not among the types which are covered by Medicare Part B.

Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drugs and to pay for the self-administered drugs.

Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the SNF care provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for SNF care.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with pneumonia and C. difficile infection. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. She was noted to not feel well and labs and chest x-ray ordered which returned with leukocytosis and she was sent to the hospital. Regarding rehabilitation services, the enrollee received speech therapy in the SNF. By the dates in question, the enrollee tolerated a regular diet and thin liquids.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily. This enrollee does 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 pay for the skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the root canal (D3330), the filling (D2391), and the additional periapical x-ray (D0230).

You asked the Plan to reimburse more for the dental services. You say that the issue at hand is the $1,500 charge for a root canal because no one in your area was in your plans network. The Plan denied your request. The Plan says there is a $500 allowance each year for covered dental services. The Plan also says that the allowance has been exhausted.

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 and the services could be covered, the annual allowance has been exhausted.

The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to reimburse more for the root canal (D3330), the filling (D2391), and the additional periapical x-ray (D0230).