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

We decided that the Plan does not have to pay for nurse practitioner services.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 nurse practitioner services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 coronary artery bypass grafting and aortic valve surgery. 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 this 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroplasty (27130AS) provided on June 15, 2020.
You asked the Plan to pay for the arthroplasty. You say that you would like reconsideration because the assistant surgeon was called into the operation by the primary surgeon to provide medically necessary care for the safety and well-being of the patient. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty (27130AS) provided on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport

You asked the Plan to waive the copayment for the ambulance transport. You say that the out-of-pocket maximum had been met so you should not owe the cost. The Plan denied your request. The Plan says the copayment 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 $220 copayment for Medicare-covered ambulance benefits.

You have been asked to pay $67.83, which is less than the $220 copayment for the ambulance transport, because your maximum out-of-pocket was met. The ambulance transport falls within the "Ambulance services" benefit category. The records show your out-of-pocket maximum was not met prior to the ambulance transport. 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 ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Otto Bock x3 knee microprocessor.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have been approved for a new lower limb prosthesis. You have a functional ambulation level of K3. The requested Otto Bock x3 knee microprocessor appears to exceed your medical needs and is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Otto Bock x3 knee microprocessor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy.

You asked the Plan to waive the copayment for the colonoscopy. You say that your primary care recommended you have a colonoscopy screening done. You say that this should have been billed as a screening not diagnostic which generates a copayment. The Plan denied your request. The Plan says the copayment 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 $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.

You have been asked to pay a $125 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show two polyps were removed, which is considered a diagnostic surgical procedure.

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 colonoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement provided on December 16, 2020.
You asked the Plan to waive the copayment for nail debridement. You say that the facility was not able to trim your nails properly. You say that you now have to go to another doctor, so you are requesting a refund. The Plan denied your request. The Plan says the copayment 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 $30 copayment in a specialty physician's office for podiatry services. You have been asked to pay a $30 copayment for the nail debridement. Nail debridement falls within the "Podiatry services" benefit category. The records show the nail debridement was performed. 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 nail debridement provided on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of spondylolisthesis with no discussion of spinal instability on flexion/extension films. There is no documentation of the enrollee's height, weight or body mass index. There is imaging evidence of scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. Therefore, the request for Vertiflex Superion Device 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom CG glucose monitor.

You asked the Plan to pre-approve a Dexcom CG glucose monitor. You say that the enrollee prefers this brand. The Plan denied your request. The Plan says the enrollee must use the Plan's preferred brand.

The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. The requested item is not the Plan's preferred brand. There is no medical justification provided in the records demonstrating why the enrollee cannot use the Plan's preferred brand. Based on this information, we decided that Medicare rules for coverage of a Dexcom CG glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom CG glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided October 12, 2020.
You asked the Plan to pay for the limited oral evaluation and intraoral x-rays. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says you have exceeded your dental allowance for the oral evaluation and the x-rays are not covered under your dental 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. The EOC says that the Plan covers two oral evaluations every calendar year. It also says that the Plan does not cover intraoral x-rays. We looked at your claim history, the case file, and Medicare rules. Based on this information, we determined that the Plan has already covered two oral evaluations in the 2020 calendar year. Additionally, we have determined that intraoral x-rays are not covered under your Plan's dental benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September
10, 2020, by an OON provider.
You asked the Plan to pay for the physician service. You say that the provider in this case depends upon the
hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company.
You say that the services were rendered in good faith. The Plan denied your request. The Plan says the provider
in this case is out of network. The Plan says that the referring facility is out of network. The Plan says that the
enrollee's primary care physician (PCP) did not refer them for the services. The Plan also says that the services
were not urgent or emergent in nature.
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 subsequent nursing facility care provided on
September 10, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 with a past medical history of end stage renal disease, hypertension and back pain who is living at home with increased weakness. 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 this 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on September 15, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you did not have the procedure done. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $40 copayment for an office visit. Since an office visit with a specialist did take place, the correct copayment has been applied. An office visit falls within the physician/practitioner services/in-network/specialist 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 an office visit provided by a participating provider on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are
medically stable, and your needs can be met 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.

Continued SNF services were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you
received oral medications and had stable vital signs. There are no skilled nursing service needs. Regarding
rehab services, you were at a modified independent to supervision assist level with functional mobility. You
required varying assist with activities of daily living. There are no identifiable skilled therapy service needs.
You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or
intensity of service criteria for an inpatient basis in a 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9330).

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9330 has a status indicator of I which is not valid for Medicare purposes.

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 S9330 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9330 has a status indicator of I. This means that CPT code S9330 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal (CPT code D6750) and pontic - porcelain fused to high noble metal (CPT Code D6240).
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not a covered benefit under 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 items or services are not among those covered under this benefit. The services are not listed in your handbook as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal (CPT code D6750) and pontic - porcelain fused to high noble metal (CPT Code D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the records do not indicate that the enrollee is in need of services that are not available in the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.