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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member no longer requires daily skilled therapy to be delivered by a licensed therapist, as the member primarily requires repetitive and routine assist, which can be executed by friends, family or other non-skilled person.

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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cystourethroscopy (CPT code 52356), and urography, (CPT Code 74420) provided to the enrollee on August 19, 2020, by an out-of-network provider.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says there is no referring provider involved in these services. The Plan states the services are not considered urgent/emergent in nature. The Plan states prior authorization was not obtained as required under the plan benefits, and services rendered by nonparticipating providers require prior authorization as outlined in the enrollee's EOC.

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 cystourethroscopy (CPT code 52356), and urography, (CPT Code 74420) provided to the enrollee on August 19, 2020, 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.

You asked the Plan to pay for the services provided. You say that you had no coverage with your primary insurance at the time the services were provided. The Plan denied your request. The Plan says the provider will need to submit the claim to the primary insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The records show that at the time of service, the Plan was the secondary insurer. The Plan has met its obligation with regards to coordination of benefits. The records show that the plan made several attempts to the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the room and board charges from the skilled nursing facility (SNF).

You asked the Plan to pay for the SNF room/board charges. You say that you were told that the Plan covers up to 20 days of SNF care after knee surgery. You feel that this is being denied only because you walked 150 feet after surgery, but this was before the anesthesia drugs fully wore off. You state that you required 24-hour care for 10 days and were not able to care for yourself or even walk to the bathroom. You believe that this means that the plan must pay for the daily room/board charges. The Plan denied your request. The Plan says it was found that you agreed to pay $335 per day out of pocket for the care received at this nursing home. This was private pay for room/board only. No daily skilled nursing or skilled therapy services were provided during this time, and you did not obtain authorization from the plan for this stay to be covered.

The Plan must follow Medicare rules. Medicare rules say that plans may require authorization in order for services to be covered. The rules also say that SNF care is only covered for patients who require daily skilled nursing or daily skilled therapy care. Custodial care is not covered.

We reviewed the file and the Medicare rules. We find that you were admitted to the SNF for custodial care, for which you agreed to pay a daily charge for room/board. You did not ask for the Plan to authorize coverage for this stay. The SNF did not submit a bill for Medicare-covered daily skilled care. We find that the Plan has no obligation to make payment for the custodial care provided for which you agreed to pay privately. Therefore, we decided that the Plan does not have to pay for the room and board charges from the skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922).

You asked the Plan to pay for the hemostatic agent. You say that the hemostatic agent was medically necessary for the procedure. The Plan denied your request. The Plan says the hemostatic agent is not covered under your benefits.

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 primary procedure is not covered by Medicare, the service at issue is also not covered by Medicare. 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 placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management.

You asked the Plan to pay for hospital discharge day management. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support a hospital discharge day management services of 31 minutes or more.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, the records submitted do not show that this hospital discharge day management was more than 30 minutes in duration. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of hypertension, chronic pain, chronic kidney disease stage 3, and frequent falls. She is living at home with increasing weakness and frequency of falling. Her 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.

Additionally, 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.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refractive state determination provided by
an out-of-network provider.

You asked the Plan to pay for the eye exam and refractive state determination. The Plan denied your request.
The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the eye exam and refractive state determination
provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that SNF care has been recommended to regain your strength. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 of this letter 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 that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial. 

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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were informed the copayment is based on a semi-private room rate, but there was only private rooms. You say that you need to file an appeal for the difference between private and semi-private room charges. 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 $275 copayment per day, days 1 to 7 at an in-network inpatient hospital. Your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type.

You have been asked to pay a $550 copayment for the inpatient stay. ($275/day x 2 days = $550). The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81401, 81403, 8140481405, 81407, 81408)
provided on August 10, 2020.
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your
request. The Plan says this was billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent
laboratory, but the records indicate that the same was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the
Plan does not have to pay for genetic testing (81401, 81403, 8140481405, 81407, 81408) provided on August
10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor knee.

You asked the Plan to pre-approve a microprocessor knee. You say that these services are medically necessary.
The Plan denied your request. The Plan says that your current knee is under warranty, in good condition, and
your functional status has not changed.

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 microprocessor knee. Our reviewer
says that the requested microprocessor knee is not considered medically reasonable and necessary in this case.
The requested knee exceeds your medical needs. The documentation does not reveal that you have had a
significant functional change, or that the current knee is damaged. Additionally, the documentation indicates
your current knee is under warranty. Our physician reviewer found that your condition does not meet Medicare
criteria for a microprocessor knee.

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 microprocessor knee have not been met. Therefore, we decided that the Plan
does not have to pre-approve a microprocessor knee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on August 20, 2020.

You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment testing/panels.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The lab requisition form submitted does not show that this testing was being ordered for screening purposes. The file does not show that the plan provided notice that genetic tests would not be covered. Under Medicare rules, this means genetic tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on August 20, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation.

You asked the Plan to pay for ambulance transportation. You say that this was needed due to wildfires. The Plan denied your request. The Plan says this was 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 ambulance transportation. Our reviewer says that the ambulance transportation at issue was not medically reasonable and necessary. Our physician reviewer found the documentation does not support that a stretcher van would have been contraindicated in this situation. The need for expertise or lifesaving equipment during transport was not established as no acute condition was noted.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CYP gene panel (81479, 81401, 81225).

You asked the Plan to pay for a CYP gene panel. You say that this was billed correctly. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that CYP gene panels (testing for more than 1 CYP gene on same date of service) is a single unit of service. All CYP panels should be billed with 81479 and are non-covered.

We looked at the file and Medicare rules. The record shows that more than one CYP gene was tested on the same date of service, making this a CYP gene panel. This was not reported correctly with a single unit of 81479, and also is not covered. Based on this information, we decided that Medicare rules for coverage of a CYP gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a CYP gene panel (81479, 81401, 81225).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolia 60 mg/ml syringe medication (J0897).

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication does not meet Medicare criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Medicare Part B coverage. Therefore, we decided that the Plan does not have to pre-approve the Prolia 60 mg/ml syringe medication (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on March 2, 2020.

You asked the Plan to pay for the Ketamine infusion. You say that Ketamine infusions are a necessary treatment. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of Ketamine infusions for the treatment of depression.

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 pay for Ketamine infusion. Our reviewer says that the infusion was not medically necessary. Our physician reviewer found in July 2019; the International Anesthesia Research Society published the results of a systematic literature review which compiled the results from seven randomized controlled trials evaluating the long-term effectiveness of ketamine infusion for the treatment of pain. In total, the seven trials that were evaluated included 211 patients with three types of pain: neuropathic, mixed and nonneuropathic. Three of the seven studies reported significant analgesic benefit with ketamine, with a small analgesic effect that persisted for up to two weeks post-infusion. There was no difference in pain relief based on pain classification. The results suggested but did not establish, enhanced pain relief with higher doses of ketamine and in patients with complex regional pain syndrome. The analysis also concluded that additional studies enrolling a larger population of patients are needed in order to determine the efficacy of ketamine for chronic pain syndrome. 

The review has determined that the items/services at issue in this case are 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 Ketamine infusion have not been met. Therefore, we decided that the Plan does not have to pay for the Ketamine infusion provided on March 2, 2020.