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

We decided that the Plan does not have to pay for the skilled nursing services provided from May 21, 2021, to May 31, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required or received daily skilled services at an inpatient skilled nursing facility (SNF) 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 21, 2021, to May 31, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the bone density test you had on August 19, 2021.
You asked the Plan to waive the copayment for the bone density test. You say that there should be no
copayment for this service. The Plan denied your request. The Plan says that this bone density test is a
diagnostic test, so the correct copayment applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees pay $0 cost sharing for bone mass measurements.
The Plan says you must pay a $20 copayment for the bone density test. Based on the Plan contract, however,
you cannot be asked to pay more than $0 cost sharing for the bone density test (which is a type of bone mass
measurement). Therefore, we decided that the Plan has to waive the copayment for the bone density test you
had on August 19, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on May 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not had a poor response to Retacrit for at least two months with appropriate dose adjustment.

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 Aranesp. Our physician reviewer found that the enrollee has anemia related to chronic kidney disease. The Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Esomepra.  You asked the Plan to pre-approve Esomepra. 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 Esomepra.   Benefits for Esomepra 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 for the emergency office care (99058), outpatient office visit (99213), computed tomography (CT) of the maxillofacial area (70486), and drainage of mouth lesion (40800) provided on May 24, 2021.  You asked the Plan to pay for the emergency office care, outpatient office visit, CT of the maxillofacial area, and drainage of mouth lesion. The Plan denied your request. The Plan says dental services are not a covered benefit. The Plan also says that these services were not medically necessary.  Medicare generally does not cover dental services. The Plan follows the same rule.  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 emergency office care, outpatient office visit, CT of the maxillofacial area, and drainage of mouth lesion. Our reviewer says that these services are not medical in nature. Our physician reviewer found the services provided are dental in nature and could have been coded with more appropriate dental codes.  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 emergency office care, outpatient office visit, CT of the maxillofacial area, and drainage of mouth lesion have not been met. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency office care (99058), outpatient office visit (99213), computed tomography (CT) of the maxillofacial area (70486), and drainage of mouth lesion (40800) provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 6, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code
81455 are denied as not medically necessary.
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on April 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0242U) provided May 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 0242U is not supported in the medical record. Specifically, the place of service listed on
the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (0242U) provided May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on January 23, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has a difficult time ambulating and
their legs feel "weak" and painful. You state the enrollee has not had success with conservative therapies, such
as prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs), over the counter (OTC) medications,
heat/ice, stretching or home workouts. The Plan denied your request. The Plan says the Medicare criteria for
reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and
there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold
standard of decompression.
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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device remains experimental. More research is needed to show safety and
efficacy.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81210, 81235, 81275, 81276, 81295, 81298,
81317, 81401, 81301, 81191, 81309) provided May 23, 2021.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 81210, 81235, 81275, 81276, 81295, 81298, 81317, 81401, 81301, 81191, and 81309 is
not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does
not match the place of service detailed in the records (11, office setting). Based on this information, we decided
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan
does not have to pay for lab services (81210, 81235, 81275, 81276, 81295, 81298, 81317, 81401, 81301,
81191, 81309) provided May 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cup holder and a holder for a walker (CPT code
(K0108 X 2).

You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your
request. The Plan says your request is not medically necessary because these accessories do not serve a medical
purpose.

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 to the 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 pre-approve a cup holder and a holder for a walker (CPT
code (K0108 X 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve adalimumab (Humira), 20MG injection (CPT code J0135), for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says this medication can be self-administered and is not covered under the enrollee's Part B benefit.  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 adalimumab (Humira), 20MG injection (CPT code J0135), for the enrollee.   Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new continuous positive airway pressure (CPAP) unit.
You asked the Plan to pre-approve a new CPAP unit. You say that the item is necessary. The Plan denied your
request. The Plan says you have not had your current device for 5 years. Therefore, coverage criteria have not
been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during
the reasonable useful lifetime of the equipment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a new CPAP unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a new continuous positive airway pressure (CPAP) unit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit (99205) with an out-of-network
provider on June 23, 2021.
You asked the Plan to reimburse you for the office visit. You say that you would like reconsideration because
this is the only provider available to render your necessary care. The Plan denied your request. The Plan says
100% of the maximum allowable payment was made.
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by non-contracted
providers, there is no balance billing paid by either the plan or the enrollee.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit have not been met. Specifically, you received care from an out-of-network provider.
The Plan paid their share of the cost for these services. The Plan is not responsible for paying an amount
greater than the Medicare allowed amount for this service. Therefore, we decided that the Plan does not have to
reimburse you for the office visit (99205) with an out-of-network provider on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the thorax (71250) provided
on July 20, 2021.
You asked the Plan to pay for the CT of the thorax. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says CPT code 71250 is included in 71275
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 71250
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the thorax (71250)
provided on July 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May
11, 2021, to May 31, 2021.
You asked the Plan to pay for the SNF care. You say that the enrollee was not enrolled in hospice on the dates
of service. You also say that the services rendered are not related to the enrollee's hospice diagnosis. The Plan
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on May 4, 2021. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility
(SNF) care provided from May 11, 2021, to May 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal 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 laboratory
services rendered on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code
81455 are denied as not medically necessary.
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on June 24, 2021