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

We decided that the Plan does not have to pre-approve office visit services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visit services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are multiple in-network specialist's available to the enrollee that can provide the care and treatment being requested.

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 office visit services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on August 11, 2020.
You asked the Plan to pay for codes 95957-26, 95908-26, 95885-26. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says code 95957-26 (1 unit) and 95908-26 are not supported by the medical records provided. Code 95885-26 is an add-on type code that requires a primary code. Since the primary code is not supported, this code cannot be separately reimbursed. Therefore, the billed Current Procedural Terminology (CPT) code and modifier cannot be verified. The Plan notes that multiple attempts were made to contact the provider for additional information.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, codes 95957-26, 95908-26, 95885-26 cannot be paid as billed as they are not supported in the records provided. The Plan states additional records and/or corrected claim would be reviewed if submitted. Medicare billing criteria are not met.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 11, 2020 and billed under codes 95957-26, 95908-26, and 95885-26.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on September 25, 2020 and billed under code 97110.

You asked the Plan to pay for this service. You say that the Plan should pay for these services. The Plan denied your request. The Plan says code 97110 is not supported as the records show the service is performed by a physical therapist assistant in a home health or hospice setting. The appropriate code for the service billed would have been code G0157 for the services rendered. The Plan notes multiple attempts were made to contact the provider for additional information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as billed due to an error with the code reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on September 25, 2020 and billed under code 97110.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 
The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic membrane wound care services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested service is 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 the requested services. Our physician reviewer found that the enrollee is undergoing wound care after leg surgery. Amniotic membrane treatment is indicated for non-healing ulcers and for venous status ulcers which have difficulty healing. This case shows the wound was traumatic and not impeded by any condition and was also improving according to the records. Therefore, without a clear indication or evidence suggesting the patient had failed other more conservative standard treatment options, this request will be considered not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic membrane wound care services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hydration infusion into a vein (96360, 96361) provided on October 19, 2020.
You asked the Plan to waive the coinsurance for hydration infusion. You say that you had no knowledge of any charges connected with this service. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for hydration infusion. The allowed amount of the claim is $268.77, resulting in a coinsurance obligation of $53.75. The EOC confirms 20% is the required coinsurance for this service. Hydration infusion falls within the Medicare Part B prescription drugs 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 coinsurance for hydration infusion into a vein (96360, 96361) provided on October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density scan rendered on March 12, 2021.
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 exceed the benefit limit.
The Plan must follow Medicare rules. The rules say that Medicare pays for a screening bone mass measurement (BMM) once every 2 years. We looked at the file and Medicare rules. The file shows that you previously had a bone density scan on February 26, 2020. The services on March 12, 2021 were performed less than two years from your previously covered scan. 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 bone density scan rendered on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on April 13, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you thought this would be covered because it was related t the vaccine. 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 $45 copayment for physician/practitioner services/in-network/specialist.

You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist 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 a specialist office visit provided by a participating provider on April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayments for the methadone assisted treatment (G2067, G2078) provided from January 1, 2020, through December 22, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $55 copayment for Medicare-covered opioid treatment services with an out of network provider.
You have been asked to pay $2,805 ($55 copayment x 51) for the methadone treatments rendered by an out of network provider. 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 issue reimbursement of the copayments for the methadone assisted treatment (G2067, G2078) provided from January 1, 2020, through December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311), power standing feature (E2301), or other accessories (K0108).

You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311), power standing feature (E2301), and other accessories (K0108). You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the power standing feature does not serve a primary medical purpose, the enrollee can control the power options using their own switches, and there is no separate billing for (K0108)nonstandard seat frame, seat plate, seat angle option, knee bolter horns, custom cut varilite and actuators.

The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 

The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. The other accessories (K0108) are unbundled from the approved power wheelchair and cannot be requested separately. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311), power standing feature (E2301), or other accessories (K0108).
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 the enrollee's clinical condition meets full inpatient acute rehab criteria. The Plan denied your request. The Plan says the enrollee does not require an intensive rehab program.

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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the patient would benefit from inpatient therapy daily to be able to progress back to an assisted living level. The Plan denied your request. The Plan says that the member's needs can be safely 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. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete dentures, overdentures, and surgical access to an implant body.

You asked the Plan to pre-approve the complete dentures, overdentures, and surgical access to an implant body.. You say that you are experiencing difficulty eating and are being malnourished due to not having any teeth. You say that the requested dental services are medically necessary. You say that you are on a fixed income. The Plan denied your request. The Plan says the benefit for dentures is exhausted. The Plan says that the other services in dispute are not a covered 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 benefit for dentures is limited to once every 5 years. The records show that the Plan authorized immediate dentures under authorization number 171274976 within the last 5 years. This means that your benefit for dentures is currently exhausted.

The dental benefits that the Plan offers in excess of Medicare coverage do not include coverage for overdentures or surgical access to an implant body. Therefore, we decided that the Plan does not have to pre-approve complete dentures, overdentures, and surgical access to an implant body.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee drastically needs this procedure. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because this surgery is approved as an ambulatory procedure and if the enrollee experiences any peri- or post-operative complications inpatient level of care can be reconsidered.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested inpatient hospital level of care. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. There is no documentation provided to support an expectation that the enrollee will require a greater than 2 midnight stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal stabilizer device, Coflex (CPT 22867). 
 
You asked the Plan to pre-approve the Coflex device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says Cauda equina syndrome is a contraindication for interspinous devices such 
as Coflex. 
 
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 Coflex device. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found Coflex is experimental, more research is needed to show safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Coflex device have not been met. Specifically, this item is considered 
experimental. This means the item is not medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve a spinal stabilizer device, Coflex (CPT 22867).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request pre-approve ten (10) additional PT visits.

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is
not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved
by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills
of a professional therapist are required to safely and effectively provide treatment, that the services can be
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee
does not have significant functional deficits that require ongoing physical therapy, and she has been authorized
additional sessions to ensure competence in a home exercise program. The requested services are not part of a
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have pre-approve ten (10) additional PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you need additional transportation. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 25th trip and
beyond is not a covered benefit. Your requested exceeds your benefit. Your 2021 EOC states the Plan covers up to 24 one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.