Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen contents provided on October 29, 2019.You asked the Plan to pay for the portable oxygen contents. You say that the Plan should pay this claim.The Plan denied your request. The Plan says no payment can be made for oxygen contents in a month in which payment is made for stationary equipment.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 E0443 is Portable oxygen contents, gaseous.The equipment had not met the rental cap on October 1, 2019. The benefit limit has not been met.Based on this information, we decided that Medicare rules for coverage of the portable oxygen contents have not been met.Therefore, we decided that the Plan does not have to pay for the portable oxygen contents provided on October 29, 2019
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 forthe enrollee.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 requestto pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical therapy and occupational therapy but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have topre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature power wheelchair.You asked the Plan to pre-approvethe power seat elevation feature. The Plan denied your request. The Plan says the item is not a Medicare-covered benefit.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. Therefore, we decided that thePlan does not have to pre-approvea power seat elevation feature power wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar injection provided on October 25, 2019.You asked the Plan to pay for the injection. The Plan denied your request. The Plan says there is a more appropriate code that should be used to bill for the services provided.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 64520 is injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic). 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 injection. Our physician reviewer found that the documentation does not describe the provision of a sympathetic nerve block at the thoracic or lumbar level. Therefore, the billing of CPT 64520 is not supported.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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar injection provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided June 11, 2019 to June 25, 2019.You asked the Plan to pay for the inpatient hospital services. You say that the records provided should support the services in dispute.The Plan denied your request. The Plan says the claim does not meet pre-admission bundling requirements.The Plan must follow Medicare rules. Medicare rules say that providers can bill pre-admission services on their inpatient claim as long as they are within three days of Admit Date.  Any services provided more than three days prior to inpatient admission on 5/28 cannot be included on the inpatient claim. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital services provided June 11, 2019 to June 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee needs this so she can achieve optimal diabetes management.The Plan denied your request. The Plan says that this medication is not covered under Part B.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 topre-approveTradjenta for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 14, 2016.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee was under hospice care and Medicare is the primary payer.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 14, 2016.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from September 16, 2019 to September 19, 2019.
You asked the Plan to waive the copayment. You say that you should not have to pay an additional copayment for your re-admission into the hospital as it was associated with your initial surgery. The Plan denied your request. The Plan says the copayment was applied correctly according to your contractual policy. You had two separate admissions in which cost sharing is charged for each inpatient stay.
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 for inpatient hospital care you must pay a $325 copayment for each day for days 1-4 of the admission. You have been asked to pay a $975 copayment ($325 x 3 days) for the inpatient hospital care provided. 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 hospital care provided September 16, 2019 to September 19, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX (J7321).You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Monovisc and Orthovisc as required by step therapy rules.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 todetermine if the Plan was correct in denying the request to pre-approve Supartz FX. Our reviewer says that the criteria for coverage of Supartz FX have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not support that the enrollee has tried Monovisc and Orthovisc, or that these drugs would likely be less effective or 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 Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 1mg Aflibercept injections (J0178x2) provided on July 11, 2019.You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate that a total of 2mg of Aflibercept was administered.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 J0178x2 is injection, aflibercept, 1 mg.We asked our coder 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 injections. Our reviewer says that CPT code J0178x2 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of 2mg of injection, Aflibercept 1mg.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 injections have not been met. Therefore, we decided that the Plan does not have to pay for 1mg Aflibercept injections (J0178x2) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora walk-in tub purchased through a non-contracted provider on July 23, 2019.You asked the Plan to pay forthe walk-in tub. You say that you are taking the Plans advice and suggestions to make sure your house is safe and fitted to avoid accidents. Your tub posed the greatest threat and therefore you are asking for some contributions.The Plan denied your request. The Plan says walk-in tubs are not covered as per Medicare DME as there are more cost-effective systems to aid in bathing.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 tothe 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 pay fora walk-in tub purchased through a non-contracted provider on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of nerve compression on the exam.
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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a prior injection with minimal relief. She does not have evidence of neuroforaminal stenosis from disc disease. Therefore, 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a back injection for the enrollee.vb 23 e
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for hemodialysis services (90937) provided on September 28, 2019 through September 30, 2019.You asked the Plan to pay for the hemodialysis services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the D5 Value Code is required with an amount and the provider did not submit this value code on any of their claims.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 90937 is supported in the record. Specifically, the submitted claim includes both the D5 value code and the appropriate 51 occurrence code. The provider has billed according to the Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hemodialysis services have been met.Therefore, we decided that the Plan has to pay for hemodialysis services (90937) provided on September 28, 2019 through September 30, 2019.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 24,2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says services are not covered with non-contract providers.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on October 24, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a Freestyle Lite glucose meter and test strips.You asked the Planto pre-approvethe Freestyle Lite meter. You say that your endocrinologist wants you to use a meter from which he can download data in the office.The Plandenied your request. The Plansaysthere is no evidence that it is medically necessary for you to have the non-preferred brand solely due to the preference of your doctor.The Plan must follow Medicare rules. Medicare rules say that plans are allowed to restrict coverage to certain brands of items as long as all medically necessary brands are covered. The contract with the Plan says that Arkray brands of GLUCOCARD Shine and Expression are covered.In this case, the documentation does not support that the preferred brand cannot meet your needs or that it is a medical necessity that the data be downloadable by your physician.Therefore, we decided that the Plandoes not haveto pre-approvea Freestyle Lite glucose meter and test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic procedure (97110) provided on July 9, 2019.You asked the Plan to pay for the therapeutic procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of a detailed description of the specific therapeutic exercises performed.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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility .We asked our coder 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 therapeutic procedure. Our reviewer says that the documentation indicates that the physical therapist provided supervisory services on the date of service in question. Our reviewer found there is no documentation that the physical therapist conducted therapeutic exercises with the enrollee. 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 therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic procedure (97110) provided on July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including nebulizer treatments, BiPAP, surveillance laboratory studies, decubitus wound care, wound vacuum care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 the diagnosis and condition of the enrollee 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 admission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Procrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurancethe replacement orthotic provided on November 7, 2019.You asked the Plan to waive the coinsurancethe replacement orthotic. You say that you were told there would be no deductible or copayment related to this service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 20% coinsurance for in-network Medicare-covered prostheticdevices and orthotics. You have been asked to pay $90.03 which is 20% of the allowed amount for the replacement orthotic. The allowed amount is $450.16. ($450.16 x 20% = $90.03). The replacement orthotic falls within the "Prosthetic devices and related supplies" 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 coinsurancethe replacement orthotic provided on November 7, 2019.