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

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99232) provided December 31, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that all services rendered were a medical necessity at the time of service and attached are medical notes for review. Please reconsider payment of your claim. The Plan denied your request. The Plan says this is a duplicate of a charge considered on a previous claim.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. We find that CPT code 99232 is not supported in the medical record. Specifically, the same service, rendered by the same provider, for the same date of service has been processed and paid under another claim. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care, per day (99232) provided December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinous spacer placement (22870, 22869).You asked the Plan to pre-approvethe interspinous spacer placement. You say that the procedure is medically necessary.The Plan denied your request. The Plan says this procedure is considered investigational and is non-covered.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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over traditional lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed studies to support the use of this 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 the interspinous spacer placement have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous spacer placement (22870, 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprophylaxis (D1110), diagnostic casts (D0470), implant repair (D6090), gum surgery (D4273 x 4), and an occlusal guard (D9944).You asked the Plan to pre-approvethe dental services. You say that these services are medically necessary and should be covered.The Plan denied your request. The Plan says diagnostic cast, implant repair, gum surgery, and an occlusal guard are not listed as covered services. The Plan says that prophylaxis is covered once every 6 months. The Plan also says that the frequency limit has been reached.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.Thoughthe Plan offers a dental benefit in excess of Medicare coverage, diagnostic cast, implant repair, gum surgery, and an occlusal guard are not among those covered under this benefit. Although prophylaxis is listed as a covered service, the frequency limit has been reached. The record shows that the Plan paid for a prophylaxis that you received on March 22, 2021.Therefore, we decided that the Plan does not have to pre-approveprophylaxis (D1110), diagnostic casts (D0470), implant repair (D6090), gum surgery (D4273 x 4), and an occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 01710) provided to the enrollee on October 29, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 01710 QK (165 units) remains not supported.
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 01710 is "Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not include an anesthesia report. The procedure report documents sedation was administered. There is a more appropriate code to report for this procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 01710) provided to the enrollee on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. 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 pneumonia. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy services.You asked the Plan to pre-approveadditional services. The Plandenied your request. The Plan says additional services are 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 to pre-approve additional services. Our physician reviewer found that the enrollee has had prior extensive therapy for her condition. The recordsdo not demonstrate that the unique skills of a professional therapist are required to 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 specialized skills of a qualified therapist are not required to establish, design or deliver a program to maintain hercurrent 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 additional services have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Gel-One medication (J7326).You asked the Plan to pre-approvethis medication. You say that this medication is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria for coverage of the requested medication. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 this medication. Our reviewer says that  the enrollee has not met the step therapy criteria for coverage of this medication. Our physician reviewer found that the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The case file does not contain documentation of trial and failure of the Plan's required step therapy medications Orthovisc and Monovisc. Additionally, the documentation does not support that these medications would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Gel-One medication (J7326).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe eyeglasses (V2020, V2781) purchased on December 10, 2020.You asked the Plan to pay forthe eyeglasses. You say that the Plan should reimburse you for these glasses.The Plan denied your request. The Plan says that this service cannot be covered because you used an out-of-network provider when there were two available in-network (contracted) providers in your area.Medicare generally does not coverroutine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $850 per year to be used toward the purchase of eyeglasses (frames and lenses) and/or contact lenses. The Maximum benefit amount applies for both in-network and out-of-networkWe looked at the file and the Plan's rules. The Plan denied payment for the eyeglasses on the basis that they were purchased from an out-of-network provider. However, the contract clearly states that the $850 annual allowance for eyewear may be used in-network or out-of-network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have been met. Therefore, we decided that the Plan has to pay forthe eyeglasses (V2020, V2781) purchased on December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine, Eribulin Mesylate, and Dexamethasone.
You asked the Plan to pre-approve Gemcitabine, Eribulin Mesylate, and Dexamethasone. You say that these drugs are medically necessary. The Plan denied your request. The Plan says the requested drugs are not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Gemcitabine, Eribulin Mesylate, and Dexamethasone. Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found the enrollee has been diagnosed with stage IV bladder cancer. In this case, the use of Gemcitabine, Eribulin Mesylate, and Dexamethasone is not approved by the Federal Drug Administration for the enrollee's diagnosis. Furthermore, the use of these drugs for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The patient has progressed on prior gemcitabine and combination is not supported by phase III studies.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gemcitabine, Eribulin Mesylate, and Dexamethasone have not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine, Eribulin Mesylate, and Dexamethasone.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the home health services. You say that home health care is medically necessary due to the enrollee having Alzheimer's disease. The Plan denied your request. The Plan says the requested home health care is considered custodial and not covered.
The Plan must follow Medicare rules. The rules 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 the home health services. Our reviewer says that home health services are not medically necessary. Our physician reviewer found that in order to require home health care skilled services, the enrollee 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, the enrollee 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 does not support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She requires custodial services without a skilled need for home health. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you need IRF services.The Plan denied your request. The Plansays you do not meet IRF criteria,but a lower level of care might be appropriate.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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
November 4, 2020.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says this was not billed with a correct FIPS code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim was not billed with a valid FIPS code. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve shoe inserts. You say that the enrollee needs arch supports because of knee and foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost forthe laboratory services provided on August 24, 2020 and the denosumab injection provided on August 25, 2020.You asked the Plan to waive the cost forthe laboratory services and denosumab injection. You say that the hospital waited months before they sent you a bill. You say that the matter should be resolved quickly.The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for lab services at an in-network outpatient hospital and 20% coinsurance for Medicare Part B covered drugs from an in-network provider. You have been asked to pay a total of $295.55 for the laboratory services and denosumab injection. Date of ServiceServiceAllowed AmountStandard CostMember LiabilityAugust 24, 2020Laboratory Services$285.70$50$50August 25, 2020Denosumab Injection$1,227.7320%$245.55TOTAL:$295.55The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The denosumab injection 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 cost forthe laboratory services provided on August 24, 2020 and the denosumab injection provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.