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

We decided that the Plan does not have to pay for the CxBladder testing services (0012M) provided on September 28, 2020.
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this testing is a Medicare covered benefit. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of medically necessary and reasonable and cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M , non-coverage was reaffirmed by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. Specifically, this testing is not a covered benefit per the applicable LCD. Therefore, we decided that the Plan does not have to pay for the CxBladder testing services (0012M) provided on September 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Surgery to Place a Vertiflex Superion Device (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Surgery to Place a Vertiflex Superion Device (CPT code 22869), for the enrollee.
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 care. You say that you would be more comfortable at the SNF. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not have 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 care 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that authorization was impossible to obtain due to the incorrect insurance information be given. You say that the enrollee required the medical care received and the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network with the Plan.

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 office visit provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that you must see two specialists during the same visit for every visit. You say that you were told that all visits were covered. The Plan denied your request. The Plan says this provider is not a network with the Plan.

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 office visit provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for oral exam (D0120), bitewing x-rays, 7 to 8 images (D0277), and prophylaxis (D1110) provided on November 19, 2020.
You asked the Plan to pay more for the dental services. You say that you understand that you should be reimbursed 50% when you see an out of network dentist. You say that you understand that vertical bitewings are not covered. You say that you were only reimbursed $26.50. You also say that you should be reimbursed an additional $64.50 to make up the 50% for out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you pay a 50% coinsurance for dental services that you receive out of network. The Plan says that the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan says that you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist. The Plan also says that bitewing x-rays, 7 to 8 images, are not a covered service.
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, out of network dentists can bill you for the difference between what they bill you and what the plan pays. Additionally, bitewing x-rays, 7 to 8 images, are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for oral exam (D0120), bitewing x-rays, 7 to 8 images (D0277), and prophylaxis (D1110) provided on November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee needs SNF level care as he lives alone and is unsafe to return home without rehabilitation at a SNF. The Plan denied your request. The Plan says that medical complexity does not merit skilled nursing 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 the enrollee's 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional physical therapy (PT) visits (97164).

You asked the Plan to pre-approve the additional PT visits. You say that the enrollee was previously being treated for left sided sciatica pain and was denied additional visits on her existing auth. You are requesting 10 visits for enrollee's left hip bursitis. The Plan denied your request. The Plan says the additional nine physical therapy visits are not medically necessary.

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 additional PT visits. 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 additional 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 and has a LEFS score of 19/80 which equates to housebound. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The enrollee does not require 9 more sessions of therapy for hip bursitis and the additional authorized session of therapy can instruct the enrollee on exercises for hip bursitis. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional physical therapy (PT) visits (97164).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to apply Part D cost sharing to the Prolia.

You asked the Plan to apply Part D cost sharing the Prolia. You say that you received an approval letter that indicates you remain enrolled in the Plan's Medicare Part D prescription drug plan. You say that you have been receiving this drug for several years and that it has always been processed under Part D. You say that, before enrolling with the current plan, you verified that Prolia would be covered under Part D. You say that the Prolia medicine has always been sent directly to the doctor's office and refrigerated there until your appointment. The Plan denied your request. The Plan says that Prolia is a Medicare Part B drug and is not covered under Part D. The Plan says that the drug is not self-administered and is not eligible to be paid under Part D.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The rules also say that in order to be eligible for coverage under Medicare Part B, a drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.

The Plan says you must pay a Part B cost-sharing amount for the Prolia. Review of the file shows that the Plan issued an approval, for Part D coverage for Prolia. The file also shows that this drug was administered and billed by the specialty pharmacy. This indicates that the drug did not represent an expense to the physician and was not included on the physician's bill, as it was billed directly by the pharmacy. As such, this drug would not be eligible for coverage under Medicare Part B in this case. The Plan incorrectly assessed the cost sharing for Part B drugs to this claim. Therefore, we decided that the Plan has to apply Part D cost sharing to the Prolia.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on September 24, 2020.
You asked the Plan to waive the copayment for lab test. You say that you were charged more than you were expecting. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for lab testing. You have been asked to pay $20 copayment for lab test. Lab test falls 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 testing provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on June 23, 2020.
You asked the Plan to pay for laboratory services. You say that you received the specimen and are obligated to provide the service. You say that the provider should not be penalized for providing services to the member. The Plan denied your request. The Plan says this provider is not a network with the Plan.
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 laboratory services provided by an out-of-network provider on June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says the service is not necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer found there is no specific clinical rationale for the requested CT, abdomen and pelvis; with contrast material(s) (CPT code 74177). The requested CT scan is not medically reasonable or 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of a peripheral or gastric neurostimulator pulse generator or receiver (64590) provided on November 4, 2020.
You asked the Plan to pay for the insertion or replacement of a peripheral or gastric neurostimulator pulse generator or receiver. You say that you would like reconsideration because the charge billed is not part of post-operative care. The Plan denied your request. The Plan says the documentation indicates that this was a stage 2 procedure which requires a -58 modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Modifier "-58" was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. We find that CPT code 64590 is not supported in the record. Specifically, this service was not billed with the required modifier to indicate that this was a staged procedure. Based on this information, we decided that Medicare rules for coverage of the insertion or replacement of a peripheral or gastric neurostimulator pulse
generator or receiver have not been met. Therefore, we decided that the Plan does not have to pay for the insertion or replacement of a peripheral or gastric neurostimulator pulse generator or receiver (64590) provided on November 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328.

You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve denture repair (D5751) to be provided by an out-of-network (OON) dentist.

You asked the Plan to pre-approve denture repair. You say that the dentist you want to see is the only one who will repair your dentures quickly. The Plan denied your request. The Plan says dental services are only covered in-network.

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, this benefit only covers services from in-network dentists. Therefore, we decided that the Plan does not have to pre-approve denture repair (D5751) to be provided by an out-of-network (OON) dentist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer is experimental. More research is needed to show safety and efficacy. Open laminectomy is the gold standard procedure for spinal stenosis decompression.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. You say that a SNF was recommended by the hospital and the enrollee's place of residence feels that they cannot provide the care the enrollee needs. You say that the enrollee fell twice in one week while living at the facility and she has two broken elbows with pins, a dislocated shoulder, and a broken pelvis from her recent falls. You say that the enrollee suffers from dementia and Parkinson's disease and she is not able to care for herself. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a SNF admission.

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 that the enrollee has stabilized medically and is ready for discharge from the hospital. Due to orthopedic and weight bearing restrictions the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Admission to a SNF for inpatient skilled rehab services 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.