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

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services.

You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you feel as though this service should not have a copay because it is needed to prevent future health issues. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment per visit for cardiac rehabilitation services.

You have been asked to pay a $10 copayment per visit for the cardiac rehabilitation services. This copayment applies regardless of the reason for the service. 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 copayments for cardiac rehabilitation services you.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0601).

You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied your request. The Plan says caries risk assessment and documentation is not listed as a covered service.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the caries risk assessment and documentation (D0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 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 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 an office visit provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (97530) and the occupational therapy re-evaluation (97168) rendered by the out of network (OON) provider.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 occupational therapy (97530) and the occupational therapy re-evaluation (97168) rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve plastic surgery services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that this provider has much more experience with the type of surgery you need. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan, and you can be treated by an in-network provider.

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 plastic surgery services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (82542 and 83789).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because these services were billed appropriately. The Plan denied your request. The Plan says billing CPT codes 82542 and 83789 for metabolite testing is unbundling the comprehensive code.

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, we have confirmed that codes the drug testing services have a bundled relationship with code G0482 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (82542 and 83789).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing you received on November 16, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you need to have the test before you could come back home. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the COVID-19 test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing you received on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3916).

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the record does not support the billed item in this case.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for this item. Our reviewer says that the wrist hand orthosis provided is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the right and left wrists. The documentation in the case file does not support that the wrist hand orthosis provided was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrists would reasonably be required to adequately assess whether the wrist hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists.

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 item have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care rendered from February 17, 2020 to February 21, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services were not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the criteria for inpatient care are met. Our physician reviewer found the enrollee presented to the emergency department (ED) for the evaluation of shortness of breath. The evaluation revealed hypernatremia and elevated BNP and RSV positive. A chest x-ray revealed question of a right mid lung pneumonia. The records show that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care rendered from February 17, 2020 to February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee has weakness and is at risk for falls. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs that can only be met in an IRF.

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 physician reviewer found that the enrollee was admitted to the acute hospital for transient ischemic attack. Her medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: 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 you would benefit from increased and more intense
therapy. The Plan denied your request. The Plan says the denial of IRF service is correct.

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 your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the records support
a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.

You asked the Plan to pre-approve Rituxan. You say that clinical research supports the use. The Plan denied your request. The Plan says the enrollee's diagnosis is not a medically accepted use for the drug.

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 Rituxan. Our physician reviewer found that the case file does not contain documentation of trial and failure of Truxima, Rituxan Hycela, and Ruxience. The documentation does not support that required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, criteria for coverage of Rituxan are not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (33289, C2624).
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety 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 insertion of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (33289, C2624).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve IMRT. You say that due to the enrollee's history and the proximity of the
tumor volume to the heart, vessels, and other critical structures, IMRT is the preferred treatment modality. The
Plan denied your request. The Plan says that the denial of authorization for this IMRT is correct, because the
enrollee does not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 pre-approve IMRT. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found given that National Comprehensive Cancer Network (NCCN) guidelines, as well as
conclusions from a cooperative group study, support the use of IMRT for Stage III non-small cell lung cancer
(NSCLC), this treatment would be furnished in accordance with accepted standards of medical practice.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve
intensity modulated radiation therapy (IMRT).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on May 27, 2020.
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 procedure code 01402 is 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 01402 is anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty. We find that CPT code 01402 is not supported in the medical record. Specifically, there is no documentation of anesthesia for a total knee arthroplasty. 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 anesthesia services rendered on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment, abutment supported
porcelain/ceramic crown, and two resin-based composites provided from July 2, 2020, to September 2, 2020.
You asked the Plan to pay for the prefabricated abutment, abutment supported porcelain/ceramic crown, and
two resin-based composites. You say that these services should have been covered by your plan. The Plan
denied your request. The Plan says the prefabricated abutment and abutment supported porcelain/ceramic
crown are not covered benefits. The Plan also says that the two resin-based composites were paid by the Plan at
50%.
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, prefabricated abutment and abutment
supported porcelain/ceramic crown are not among those covered under this benefit. The contract also clearly
states that you are responsible for a 50% coinsurance for resin-based composites that are provided in-network.
Therefore, we decided that the Plan does not have to pay for the prefabricated abutment, abutment supported
porcelain/ceramic crown, and two resin-based composites provided from July 2, 2020, to September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on September 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was 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 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 office services provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pain injection you received on October 7, 2020.
You asked the Plan to waive the copayment. You say that you were not charged a copayment previously for these injections. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $450 copayment for outpatient surgery services at an outpatient hospital facility. Review of the file shows that you had pain injections on October 7, 2020. You have been asked to pay a $450 copayment for the injections. The injections fall within the outpatient surgery 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 pain injection you received on October 7, 2020.