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

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that the provider is a student in an organized health care education/training program who is able to perform these services under your group. Please review and reprocess claim for payment. The Plan denied your request. The Plan says Medicare does not pay for any service furnished by a student. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 radiologic examination, chest (71045) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 25, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that pain affects the enrollee's quality of life. The Plan denied your request. The Plan says the enrollee has not had diagnostic MBBs demonstrating adequate pain relief, or a successful prior ablation at the same anatomic site.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She takes Norco for pain. She has had 2 prior Epidural Steroid injections. An MRI shows degenerative disc disease, spinal stenosis and facet arthropathy. There is no documentation submitted showing the results of diagnostic MBBs. 2 sets of diagnostic MBBs are required prior to performing the requested services. Since this has not been done, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over the bed table (E0274).
You asked the Plan to pre-approve an over the bed table (E0274). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over the bed table (E0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care items (A6222, A6446, A4452) provided on February 25, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the wound care items. You say that the denial is incorrect and should be reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained prior to these items being ordered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound care items (A6222, A6446, A4452) provided on February 25, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solostar.
You asked the Plan to pre-approve Lantus. You say that the enrollee needs this for glucose control. The Plan denied your request. The Plan says Lantus to be administered at home is not covered under the 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 pre-approve Lantus Solostar.
Benefits for Lantus 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transport (A0428 and A0425).

You asked the Plan to pay for the non-emergency transport. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says there is no documentation that the sending hospital was not able to deliver services for this member.

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 non-emergency transport. Our reviewer says that there is no documentation that the sending hospital was not able to deliver services for this member. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The documentation does not support that the member needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.

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 non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency transport (A0428 and A0425).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services in a home health setting
(G0151) and the services of a home health aide (G0156).

You asked the Plan to pre-approve physical therapy services and home health aide services. You say that the
requested services are necessary for you. The Plan denied your request. The Plan says there is no indication
that you require skilled therapy in the home. The Plan also says that this request does not meet medical
necessity criteria.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. The rules also say that HHA services may be covered if it is medically necessary for
the enrollee to receive skilled nursing or 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 physical therapy services and home
health aide services. Our reviewer says that the requested home health services are not medically necessary.
Our physician reviewer found that, in order to require home health skilled services, you must be confined to the
home, under the care of a physician, and receiving services under a plan of care established and periodically
reviewed by a physician. Additionally, you must be in need of skilled nursing care on an intermittent basis or
physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being
homebound means leaving home is a major effort. In this case, the documentation doesn't support that you
require additional skilled rehab services to provide treatment that is medically necessary. You do not require
additional rehab services to effectively provide treatment, care, and/or services in order to improve your
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have
been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Your
functional status appears to be at your baseline and you are independent with a home exercise program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy services and home health aide services have not been met.
Therefore, we decided that the Plan does not have to pre-approve physical therapy services in a home health
setting (G0151) and the services of a home health aide (G0156).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
You asked the Plan to pre-approve home visits for assistance with activities of daily living and personal care. You say that you are a great fall risk and are alone in the home of several hours a day, posing a great risk to your health. The Plan denied your request. The Plan says rules for home health services have not been met.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home visits for assistance with activities of daily living and personal care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate artery embolization (36248, 37243, 76937, 36247).
You asked the Plan to pre-approve a prostate artery embolization. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 a prostate artery embolization. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic Benign Prostatic Hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association guidelines do not recommend this procedure outside of a clinical trial 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 a prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate artery embolization (36248, 37243, 76937, 36247).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lipiflow treatment with a tertiary provider.
You asked the Plan to pre-approve the requested services. You say that your chronic dry eye has been a major health issue. The Plan denied your request. The Plan says the requested treatment is not covered, and your care can be provided by a community ophthalmologist.
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 requested services. Our physician reviewer found that you have bilateral dry eye syndrome. The notes document that dry eye syndrome will usually improve with treatment with lubrication of the eye and possible use of topical anti-inflammatory eye drops. It is noted that dry eye disease is a chronic condition that cannot be cured. It requires long term treatment. The clinical documentation does not support that Lipiflow treatment is medically reasonable and necessary. The documentation does not support that a tertiary level care is 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Lipiflow treatment with a tertiary provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient mental health treatment provided on June 10, 2020, through June 15, 2020.
You asked the Plan to pay for inpatient psychiatric hospital services. You say that you would like reconsideration because the inpatient services were medically necessary. The Plan denied your request. The Plan says that the member's symptoms and treatment could have been managed in a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the member required inpatient mental health treatment and active treatment was taking place on the billed dates of service. Our physician reviewer found the services were reasonably expected to improve the member's condition. The member was treated under an individualized treatment and the records were supervised and evaluated by a physician. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pay for acute inpatient mental health treatment provided on June 10, 2020, through June 15, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional payment for robotic assistance for surgery (S2900).
You asked the Plan to pre-approve additional payment for robotic assistance for surgery. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this technique is integral to the primary surgical procedure and is not a separately reimbursed service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code S2900 is not in the medical record. Specifically, the record indicates that the primary surgery service has been approved. The robotic assistance is considered integral to this primary surgery and is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of robotic assistance for surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve additional payment for robotic assistance for surgery (S2900).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ketamine infusion therapy provided on June 15, 2020.
You asked the Plan to pay for ketamine infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is experimental.
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 pay for ketamine infusion therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered investigational as additional studies enrolling a larger population of patients are needed in order to determine the efficacy of ketamine for chronic pain syndrome. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ketamine infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for ketamine infusion therapy provided on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the trastuzumab injections provided from January 3, 2019, through April 9, 2019.
You asked the Plan to waive the coinsurance for the trastuzumab injections. You say that a claim must be filed by a provider within 90 days. You say that you are appealing the bill due to timely filing. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% of the cost for Part B covered prescription drugs from an in-network provider. The enrollee has been asked to pay a total of $3,838.52 for the trastuzumab injections.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 3, 2019
Trastuzumab Injection
$1,685.25
20%
$337.05
January 10, 2019
Trastuzumab Injection
$1,685.25
20%
$337.05
January 17, 2019
Trastuzumab Injection
$1,685.25
20%
$337.05
February 26, 2019
Trastuzumab Injection
$6,741
20%
$1,348.20
March 19, 2019
Trastuzumab Injection
$5,055.75
20%
$1,011.15
April 9, 2019
Trastuzumab Injection
$4,270.10
20%
$468.02-less than standard 20%
TOTAL:
$3,838.52
The trastuzumab injections fall within the "Medicare Part B prescription drugs" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the trastuzumab injections provided from January 3, 2019, through April 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at a skilled nursing facility level.
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 surgical repair of a hip fracture and non surgical management of a humeral fracture after a fall. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.