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

 We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 10, 2021.  You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the provider failed to notify the Plan regarding services and subsequently an authorization was not issued.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Privigen (intravenous immune globulin (IVIG)).

You asked the Plan to pre-approve Privigen. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documentation to support the target serum trough level greater than 600mg/dl.

The Plan follows Medicare rules. Medicare rules state that intravenous immune globulin (IVIG) such as Privigen may be covered under certain clinical conditions. 

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 Privigen. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Privigen. Our physician reviewer found if a patient requires a target serum trough greater than 600mg/dl, the prescriber must provide documentation supporting the target serum level. Based on the records, the review is not able to determine if the enrollee meets this criterion. The requested use of Privigen is 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 Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Privigen (intravenous immune globulin (IVIG)).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous intraoperative monitoring rendered on April 5, 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 procedure code G0453 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes G0453 (continuous intraoperative monitoring) and 95940 (continuous intraoperative neurophysiology monitoring in the operating room). Code G0453 is a column II code with a modifier indicator of 1 when billed with column I code 95940. Code G0453 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative monitoring rendered on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the dental services provided on August 3, 2021.  You asked the Plan to pay for the dental services. You say that half of the dental procedure should have been paid by the Plan and the lesion excision should have been paid as a medical procedure. The Plan denied your request. The Plan says that the services were billed incorrectly, and you are not responsible for payment.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that an appropriate diagnosis was not submitted on the claim. There is no rule that requires a dental provider to submit diagnosis codes in order for the dental claim to be considered for payment. Therefore, we decided that the Plan has to pay for the dental services provided on August 3, 2021.   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: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency room services provided to the enrollee on  June 11, 2021 under code 99283.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says routine services are not covered in an emergency room setting. This diagnosis code does not support an emergency medical condition for emergency department services; the original denial is upheld.  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, this claim cannot be paid as it was submitted with an inappropriate emergency room code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on June 11, 2021 under code 99283.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on May 12, 2021.  You asked the Plan to pay for these services. You say that this is the way you were told to bill this claim. The Plan denied your request. The Plan says this claim was billed with an invalid place of service code.  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 cannot be paid as billed due to an error with the place of service code.           Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 12, 2021.
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 the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 40 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. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the fasenra pen.  You asked the Plan to pre-approve the fasenra pen. You say that the drug is medically necessary. The Plan denied your request. The Plan says this drug is not FDA approved for the enrollee's diagnosis.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the fasenra pen. Our reviewer says that this drug is not medically necessary. Our physician reviewer found there is no documentation that Fasenra Pen is Food and Drug Administration-approved for the enrollee's diagnosis of severe asthma without an eosinophilic phenotype and its use is not supported by any of the major drug compendia.       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 fasenra pen have not been met. Therefore, we decided that the Plan does not have to pre-approve the fasenra pen.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 to pre-approve Eliquis.   Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydromorphone and methadone tablets.

You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

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 to pre-approve hydromorphone and methadone tablets.

Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more toward the prophylaxis, periodic oral evaluation and fluoride application provided on August 5, 2021.  You asked the Plan to pay more toward the prophylaxis, periodic oral evaluation and fluoride application. You say that you understand the reason for the denial, but the charge associated is $42 not $130. You say that it doesn't appear the cleaning and exam were not covered, and the claim should be reviewed for payment. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the allowed amount for a prophylaxis and periodic oral evaluation from an out-of-network provider. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. You are also responsible for the full cost of the fluoride application as it is not a covered benefit. Therefore, we decided that the Plan does not have to pay more toward the prophylaxis, periodic oral evaluation and fluoride application provided on August 5, 2021.
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 are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for 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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an intensive approach to rehabilitation care.

While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs to be at 100% before going home to his mother, who cannot help him at this time. The Plan denied your request. The Plan says the enrollee's needs can be 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 the enrollee received oral medications, had stable vital signs, and was to complete a course of oral antibiotics. The enrollee received physical therapy in the acute hospital and was at a maximal assist level with functional mobility. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for services billed under codes 85049 and 85014.  You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, codes 85049 and 85014 are components of code 85027 which was paid and cannot be billed separately.  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 85049 and 85014 are components of code 85027 and cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for services billed under codes 85049 and 85014 for date of service May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation (D9222 and D9223) provided by a participating provider.

You asked the Plan to pay for deep sedation. You say that you need to be put under in order to get your teeth pulled. The Plan denied your request. The Plan says the requested services are not a Medicare 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep sedation (D9222 and D9223) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care.  You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee has active intent to kill herself and tried to harm herself. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has received 222 covered days of inpatient psychiatric care therefore the 190-day lifetime benefit has been exhausted.  The Plan must follow Medicare rules. Medicare rules say that inpatient psychiatric care is covered for up to 190 days in an enrollee's lifetime.   We looked at the file and Medicare rules. The enrollee has received 222 covered days of inpatient psychiatric care; therefore, the 190-day day lifetime benefit has been exhausted. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 the enrollee appears to be improving and requires only short-term additional acute care treatments that can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not available at the current facility.  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: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.  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 the enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee has daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee requires skilled nursing services for administration and monitoring of intravenous antibiotics. The enrollee requires daily skilled nursing on an inpatient basis in a skilled nursing facility (SNF) setting.  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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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 ultraviolet light therapy provided on September 9, 2020, by an OON provider.  You asked the Plan to pay for the ultraviolet light therapy. You say that the authorization was cancelled. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.     The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy provided on September 9, 2020, by an OON provider.