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

We decided that the Plan does not have to pay for ambulatory surgical services provided to the enrollee on February 10, 2020, by an out-of-network provider.

You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not authorized because this provider is a non-network provider who does not work with the enrollee's health plan, and the enrollee was referred by a provider who also does not work with the enrollee's plan. The Plan states the enrollee's primary care physician did not refer for 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 ambulatory surgical services provided to the enrollee on February 10, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuromuscular electrical stimulator / functional electrical stimulator.

You asked the Plan to pre-approve neuromuscular electrical stimulator / functional electrical stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a neuromuscular electrical stimulator is only covered for certain indications.

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 neuromuscular electrical stimulator / functional electrical stimulator. Our reviewer says that the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found you have multiple sclerosis that has caused foot drop. The atrophy is not associated with intact nerve supply. The elements of the coverage rule are not satisfied. Therefore, you do not meet criteria for the requested device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular electrical stimulator / functional electrical stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve neuromuscular electrical stimulator / functional electrical stimulator.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not need an intensive program with a team of health care professionals and doctors that specialize in 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of an ankle fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation system (CPT code E0483), for the enrollee.

You asked the Plan to pre-approve the system. You say that the system is beneficial for people with chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the system have not been met. The enrollee does not have a qualifying diagnosis of bronchiectasis, cystic fibrosis, or neuromuscular disease. Therefore, we decided that the Plan does not have to pre-approve high frequency chest wall oscillation system (CPT code E0483), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for breast ultrasound (CPT code 76642) provided on January 14, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Review of the file show that you received a breast ultrasound (CPT code 76642) on January 14, 2021. You were asked to pay a $60 copayment for the ultrasound. Your 2021 EOC states that enrollees must pay a $60 copayment for basic radiological services. 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 breast ultrasound (CPT code 76642) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Freestyle Libre reader.

You asked the Plan to pay for a Freestyle Libre reader. You say that the requested item is a necessity for the
enrollee. The Plan denied your request. The Plan says rules for a Freestyle Libre reader have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day nor use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of a Freestyle Libre reader have not been met.
Therefore, we decided that the Plan does not have to pay for a Freestyle Libre reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the medical services provided from
October 29, 2020, through November 25, 2020.

You asked the Plan to waive the co-payment for the medical services. You say that you relied on a letter you
received from the Plan about your out-of-pocket maximum. You state you got treatment and do not believe you
should have to pay your co-payments as you relied on the information in the letter to seek that treatment. The
Plan denied your request. The Plan says they found that three (3) of your claims had been reprocessed. The
Plan states claim 01-070320-516-34 was cancelled as it was found that the claim was a duplicate to claim 01-
082120-523-22. The Plan states claim 01-071020-516-07 was also reprocessed to deny, as the Plan had not
received medical records from the provider in order to appropriately process the claim. The Plan states due to
the reprocessing of these claims, it was determined that your out-of-pocket Maximum had not been reached.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles, and coinsurance). The Plan verified that your out-of-pocket maximum has not been
reached. Due to provider reconsiderations and a duplicate claim submission, three claims were reversed or
reprocessed, causing the Out-of-Pocket Maximum to not have been reached.

Your claims in question for when you sought treatment, had co-payments correctly applying. 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 co payment for the medical services provided from October 29, 2020, through
November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585).

You asked the Plan to pre-approve Botox injections (J0585). You say that the enrollee needs the injections to help with spasms. The Plan denied your request. The Plan says the notes do not say what other treatments the enrollee has tried.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox injections (J0585). Our reviewer says that the injection is not medically necessary. Our physician reviewer found per the LCD Botulinum toxin injections can be used to reduce spasticity or excessive muscular contractions, to relieve pain, to assist with posture and walking, to improve range of motion, to enhance the effectiveness of physical therapy, and to reduce severe spasm to allow better perineal hygiene in patients with spasticity secondary to spastic hemiplegia and hemiparesis. The documentation does not reveal evidence of objective spasticity due to spastic hemiplegia and hemiparesis on a physical exam therefore the criteria have not been met per the L33646 LCD for this injection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections (J0585) have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care on June 25, 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 the services are not separately payable.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 

We looked at the file and Medicare rules. The file shows that a physician in the same group practice billed services for the same date of service that were paid by the Plan. 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 subsequent hospital care on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740 x2) received January
4, 2021.

You asked the Plan to pay for the crown. You say that you were told you could see an out-of-network provider.
The Plan denied your request. The Plan says the requested service is not covered under your supplemental
benefit.

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. Therefore, we decided that the Plan does not have to pay for the crown
- porcelain/ceramic (D2740 x2) received January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0480 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes G0480 and G0483. Code G0480 is a column II code with a modifier indicator of 1 when billed with column I code G0483. Code G0480 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from November 21, 2020, through December 21, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services were not medically necessary.

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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He tolerated his TLSO brace. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a supervision to independent level with functional mobility including gait to 200 feet with a rolling walker. He could negotiate 12 stairs with contact guard assist to supervision. The enrollee required varying assist with activities of daily living.

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 SNF services provided from November 21, 2020, through December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the unspecified preventive service (D1999)
provided on October 26, 2020.

You asked the Plan to reimburse more for the unspecified preventive service. You say that you were very
discouraged initially when you found out that one 1 in network provider was available in the enrollee's area.
You say that you were told my multiple plan representatives that 45% of the service would be covered. You
say that the enrollee was only reimbursed $60 out of the $435 that he paid out of pocket. You also say that the
enrollee should have been reimbursed $195 for the services. The Plan denied your request. The Plan says
unspecified preventive service is not listed as 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, the unspecified preventive service is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse
more for the unspecified preventive service (D1999) provided on October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 1, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the requested ambulance transportation is not medically reasonable and necessary. Our physician reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on September 1, 2020. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 23, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that you got sick at the hospital. You say that the hospital should be responsible for 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 $325 for Medicare-covered ambulance services per trip. 

You have been asked to pay $82.84, which is less than the standard $325 copayment for the ambulance transport because you met your maximum out-of-pocket. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on December 23, 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 enrollee does not need 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. 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 surgical treatment of a right ureteral neoplasm and was discharged with home health services. 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 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 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.