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

We decided that the Plan does not have to pay for the self-administered drugs provided from January 16, 2021 to January 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered under the enrollee's Medicare Part B 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 pay for the self-administered drugs provided from January 16, 2021 to January 17, 2021. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and inhalation treatment provided on May 8, 2019.
You asked the Plan to waive the copayment for the office visit and inhalation treatment. You say that you paid a $5 copayment at the time of service which is what insurance required. You say that the $25 copayment is an error and you do not owe anything for this visit. The Plan denied your request. The Plan says the copayments 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 $5 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professional in a primary care provider's office and a $20 copayment for each Medicare-covered pulmonary rehabilitative visit. You have been asked to pay a $5 copayment for the office visit and a $20 copayment for the inhalation treatment. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The inhalation treatment falls within the "Pulmonary Rehabilitation Services" 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 office visit and inhalation treatment provided on May 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is medically necessary. The Plan denied your request. The Plan says the durable medical equipment being requested serves the same purpose as equipment already provided to the enrollee
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has received a portable oxygen tank and home oxygen concentrator in August of 2020. The portable oxygen tank and home oxygen concentrator serves the same purpose as the requested a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are weak and need time to recover. You say that you get lightheaded and dizzy and do not want to be sent home alone. You say that you need your energy and oxygen to improve. The Plan denied your request. The Plan says the records do not show that the enrollee needs more than 1 type of therapy. The Plan says that the records do not show that the enrollee needs an intensive program with a team of health care professionals and doctors that specialize in complex medical needs, as well as rehab.
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 Coronavirus pneumonia. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation received on April 7, 2021.

You asked the Plan to pay for the periodic oral evaluation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation received on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth guard (D9945).
You asked the Plan to pre-approve the dental item. You say that you need a new mouth guard. You also say that this is medically necessary. The Plan denied your request. The Plan says the requested item is dental in nature. The Plan says that the requested item is unrelated to the Medicare limited clinical indications. The Plan also says the requested item is not eligible for coverage by Medicare or 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 mouth guard is not among those covered under this benefit. Additionally, the item you are asking the Plan to pre-approve involves
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 Plan does not have to pre-approve a mouth guard (D9945).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can safely and effectively be provided at a lower level of 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 17, 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 codes 97116 and 97110 are 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 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). The definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT codes 97116 and 97110 are not supported in the medical record. Specifically, the records
show that the services were performed in the home setting and there are more appropriate codes for these services. 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 physical therapy services rendered on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block injection.
You asked the Plan to pre-approve genicular nerve block injection. You say that you are in pain and this service is medically necessary. The Plan denied your request. The Plan says the requested 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 genicular nerve block injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have chronic left knee pain. You take Flexeril, Ibuprofen and Cymbalta for pain. The requested service is considered an experimental/ investigational procedure that is the subject of ongoing clinical trials. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block injection have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee's ongoing care needs can be met at a different level of care.
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 the enrollee appears to be still critically ill requiring short-term acute care services, which can safely be administered at the current facility until a more appropriate transfer location is determined. The enrollee does not require services at the LTACH that are not already available at the current facility. There is no clear advantage to transfer to LTACH at this time. Transfer to a lower level of care may be considered when treatment has completed and if the enrollee is more stable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271) every 4 weeks.
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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. Our reviewer says that Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested use of Keytruda is not 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 Keytruda have not been met. Specifically, the file does not show that Keytruda is FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271) every 4 weeks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 17, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 17, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not require intensive rehabilitation and does not have complex medical rehabilitation needs.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke after recent
thoracic spinal surgery for osteomyelitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergency transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you cannot drive and need
transportation to your appointments for the rest of the year. The Plan denied your request. The Plan says you
have exhausted all of the transportation trips for this year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 20 one-way trips to plan approved locations every year trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide additional non-emergency transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 5, 2021.
You asked the Plan to waive the copayment for laboratory tests. You say that the laboratory tests were part of your annual physical. You state that you could not receive the laboratory tests on the same day due to the Coronavirus. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for laboratory tests. You received laboratory tests on March 5, 2021. Laboratory tests are subject to cost-sharing charges and are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory tests provided on March 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheezing evaluation provided on December 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the wheezing evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 wheezing evaluation provided on December 2, 2020 by an out-of-network (OON) provider.