Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on May 18, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the nurse advised you in the hospital that these drugs were necessary for you to take. You also say that you should not be held responsible for these charges. The Plan denied your request. The Plan says these self-administered drugs are 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 to pay for the self-administered drugs provided on May 18, 2021.

Benefits for the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will have problems getting out of bed. The Plan denied your request. The Plan says the enrollee does not require aggressive therapies to properly regain function.

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 care hospital for elective hip replacement. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 23, 2021 by an out-of-network provider.

You asked the Plan to pay for collection of venous blood by venipuncture (36415), assay of creatinine (82565), Computed tomographic angiography (74174), or Low osmolar contrast material (Q9967). You say that the enrollee wishes to continue services with this physician. The Plan denied your request. The Plan says the services were not urgent or emergent nor approved in advance.

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 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 physician services provided on April 23, 2021 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 19, 2021, to April 27, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were waiting on a skilled nursing facility approval that ultimately was denied. You state that you were sent home with little help and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $150 copayment for days 1-7 for inpatient hospital care. 

You have been asked to pay $900, which is less than the total copayment amount for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from April 19, 2021, to April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for outpatient diagnostic testing provided on February 10, 2021.

You asked the Plan to reduce the copayment for outpatient diagnostic testing. You say that the services are only a reading of a pacemaker by a device which transmits information. You say that this is an interrogation, not a diagnostic benefit. 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 a $35 copayment for outpatient diagnostic tests.

You have been asked to pay a $35 copayment for outpatient diagnostic testing. The records show the services rendered are diagnostic services. Outpatient diagnostic testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 reduce the copayment for outpatient diagnostic testing provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392)
provided November 24, 2020.

You asked the Plan to pay for the filling. You say that you rarely need dental work done and were following
your dentist's instructions. The Plan denied your request. The Plan says you exceeded frequency limits for this
service in 2020.

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. The Plan covers fillings twice
per calendar year.

We looked at the file and Medicare rules. The Plan provided documentation showing that fillings were
previously covered on September 29, 2020, and October 27, 2020. Based on this information, we decided that
the Plan's frequency limit for coverage of the filling has been exceeded. Therefore, we decided that the Plan
does not have to pay for the resin-based composite - two surfaces, posterior (D2392) provided November 24,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95811) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON sleep study. You say that this service is necessary. The Plan denied your request. The Plan says out-of-network services are only covered in limited circumstances. The requested sleep study can be received from 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 a sleep study (95811) to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee is not stable for discharge from the hospital.

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 is at a minimal to moderate assist level for sitting up and transfers. She is at total assist for bathing and dressing. She does not require the intensity of services provided at an IRF. Specifically, she is not shown to be able to tolerate fifteen hours per week of rehabilitative services and regular physician evaluation.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of head or brain coded
as 70450 provided May 5, 2021.

You asked the Plan to pay for the CT scan of head or brain. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says an appropriate modifier was not billed with
this code as required by Medicare rules.

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 70450 has a
bundled relationship with code 70496 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 computed tomography (CT) scan of head or brain coded as 70450 provided
May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on March 17, 2021.

You asked the Plan to pay for the dental service. You say that you already paid $150 for when you thought was the extraction that you had. You say that you would like a one-time exception to be made for the evaluation. You say that you are on a fixed income and cannot afford this bill. You also say you did not realize that you went over the limit for this service. The Plan denied your request. The Plan says 1 emergency oral evaluation is covered every 12 months. The Plan also says that the frequency limit has been exceeded.

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 and emergency oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on February 23, 2021. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on March 17, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an outpatient surgery provided by an out-of-network provider on
February 8, 2021.

You asked the Plan to pay for an outpatient surgery. You say that these services were medically necessary. The
Plan denied your request. The Plan says that prior authorization was not obtained for these services.

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 has failed to send in a 2021 Evidence of Coverage (EOC). Therefore,
we decided that the Plan has to pay for an outpatient surgery provided by an out-of-network provider on
February 8, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from September 18, 2020, through September 28, 2020.

You asked the Plan to pay for hospital services. The Plan denied your request. The Plan says there is a lack of complete medical records after multiple efforts made to obtain the records.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided from September 18, 2020, through September 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (CPT code G0299 X 40) and physical therapy visits (CPT code G0151 x 24).

You asked the Plan to pre-approve the visits. You say that you need assistance and meet requirements based on medical need and inability to leave home. The Plan denied your request. The Plan says they are denying coverage at the in-network benefit level for the requested service/items(s) by an out-of-network provider or facility. The Plan is also denying the services because they are not needed.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 visits. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require additional 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. There is no indication that the approved home health services are not sufficient to manage and treat the enrollee's medical conditions. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits (CPT code G0299 X 40) and physical therapy visits (CPT code G0151 x 24).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites (D2391 x3) provided on
May 7, 2021.

You asked the Plan to pay for the resin-based composites. You say that the enamel of your teeth was worn
away making it very rough and painful for you which is why you needed this service. The Plan denied your
request. The Plan says this service is not covered.

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 three
resin-based composites (D2391 x3) provided on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA multigene panel testing.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of grade two endometrial cancer. You had surgery on March 29, 2021. Common hereditary panel testing was ordered. It is not established that all of the genes in the requested panel are relevant to your personal and family medical history. The testing is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA multigene panel testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar pain and has been treated with medication, including opiates. She underwent a single medial branch block (MBB) in June of 2021 that resulted in 40 percent pain improvement. A second confirmatory MBB is not documented. The criteria for coverage of RFA are not met, as there is no documentation of at leaset two MBBs that provided a minimum of 80 percent sustained pain relief. The RFA is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on January
15, 2021.

You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like reconsideration
because the member had multiple exams on the same date of service. The Plan denied your request. The Plan
says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76705 and
93976.

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 code 76705
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Please note, this code pair allows a modifier to indicate a distinct service, but no modifier has been
billed. 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 ultrasound of the abdomen (76705) provided on January 15, 2021.
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 the SNF services. You say that the enrollee would do best in SNF level of
care. You say that the enrollee needs skilled nursing services and is unable to go home. The Plan denied your
request. The Plan says the enrollee can safely receive the services needed in the current inpatient rehabilitation
facility setting.

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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically
and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee
has tolerated inpatient rehabilitation services and continues to improve with daily skilled nursing and/or skilled
therapy services. He could benefit from continued services at the current level of care. The enrollee has made
slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. He can
continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when
appropriate. There are no services offered at a SNF that are not offered at an inpatient rehabilitation facility.
Admission to a SNF for inpatient skilled rehab services is 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.