Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee on March 24, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT code 99601 is assigned a status code I = Not valid for Medicare purposes. As the claim was billed with a CPT/HCPCS code which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim the plan would accept a submission of a corrected claim to consider services for payment. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee on March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided January 17, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you do not understand the cost of the service. The Plan denied your request. The Plan says the copayment was applied 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 $250 copayment for each one-way Medicare-covered ground ambulance trip.     You have been asked to pay a $250 copayment for the ambulance services. This service falls within the Ambulance services 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 ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided January 17, 2021.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the copayment for the emergency room visit (99285) provided from  June 11, 2021, through June 12, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.  

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 you must pay a $50 copayment for each Medicare-covered emergency room visit. If you are immediately admitted to the hospital, your cost sharing amount for the emergency room visit will be waived.   

The Plan says you must pay a $50 copayment for the emergency room visit provided. Based on the Plan contract, however, you cannot be asked to pay a copayment for an emergency room visit if you are immediately admitted into the hospital thereafter. The medical records provided by the plan indicate that you were immediately admitted into the hospital for observation after the emergency room visit provided. Therefore, we decided that the Plan has to waive the copayment for the emergency room visit (99285) provided from June 11, 2021, through June 12, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a joint aspiration procedure performed on July 28, 2021.  You asked the Plan to waive the deductible for the joint aspiration. You say that the charges seem excessive. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 there is $950 deductible which applies to certain items and services.   The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $950 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the joint aspiration was received on July 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a joint aspiration procedure performed on July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Prolia.  You asked the Plan to pre-approve Prolia. You say that your bone health has remained optimal since starting Prolia and you need to continue the scheduled course of treatments. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Prolia is not medically necessary for you.  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 Prolia. Our reviewer says that you do not meet the Medicare criteria for the requested use of Prolia. Our physician reviewer found Prolia is Food & Drug Administration (FDA) approved for your condition. However, there are no recent medical records provided which confirm the diagnosis with bone density testing and that you have tolerated and benefitted from treatment with Prolia.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up to 2 hours) (99601) provided from March 24, 2021, to March 31, 2021.  You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that procedure code 99601 - home infusion/specialty drug administration, per visit (up to 2 hours) - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Specifically, the record shows that the procedure code in this case is not valid for Medicare purposes as it has a Status Code of "I". Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up to 2 hours) (99601) provided from March 24, 2021, to March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for WATS 3D testing (88361) provided on April 30, 2021.  You asked the Plan to pay for WATS 3D testing. You say that this is a covered service. The Plan denied your request. The Plan says this was 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 pay for WATS 3D testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted documentation is insufficient to support that the WATS 3D testing was medically reasonable and necessary for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of WATS 3D testing have not been met. Therefore, we decided that the Plan does not have to pay for WATS 3D testing (88361) provided on April 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.  You asked the Plan to pre-approve 8 additional physical therapy visits. You say that this is the only thing that gives relief and the only thing the doctor recommended. You say that the physical therapy prescription has been renewed because it's the only thing recommended for long-term relief. The Plan denied your request. The Plan says additional visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   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 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior extensive therapy for this condition and should be able to transition a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).  You asked the Plan to pre-approve the complete mandibular denture. You say that your denture falls out when you eat and speak. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.  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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received an immediate mandibular denture on January 22, 2019 and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) services.  You asked the Plan to pre-approve the additional PT. You say that the enrollee's surgeon has strongly recommended continued therapy otherwise it is noted she may not be able to walk again. The Plan denied your request. The Plan says the enrollee has not progressed well with therapy and at this time, further therapy is not required to improve function or prevent deterioration.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee sustained a hip fracture in July 2021. She has been receiving PT in the nursing facility but has not made much progress toward sustained ambulation. The additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy, and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been inconsistent at times in therapy participation and the documentation does not reveal ongoing skilled therapy is needed. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on April 20, 2021.  You asked the Plan to pay for the therapy services and vitamin injections. You say that the medical records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says the services are considered experimental/investigational and therefore, not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy.   In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the therapy services and vitamin injections provided on April 20, 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 these services are medically necessary. The Plan denied your request. The Plan says that your medical and therapy needs could be met in a skilled nursing unit.  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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a hip fracture due to metastatic disease from lung primary. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bilateral gynecomastia mastectomy surgery.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria is not met and the procedure cannot be authorized.  

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you only have a diagnosis of Grade II gynecomastia, based on the gynecomastia consultation on 11/4/21. There must be a diagnosis of Grade III or Grade IV gynecomastia, or abnormal breast development with redundancy. The case file does not contain documentation of unsuccessful medical management, or pain and tenderness that are interfering with activities of daily living. It is not documented that the enrollee's symptoms are refractory to medications. There was no evidence of lactation or lymphadenopathy.  

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral gynecomastia mastectomy surgery.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on November 6, 2020.  You asked the Plan to pay for the hospital discharge day management. You say that the enrollee denied hospice and the account was never opened. You also say that you would like this claim to be reprocessed and paid. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  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 November 4, 2020. 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 hospital discharge day management (99239) provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 25, 2021.    

You asked the Plan to provide additional payment for the tooth extractions. You say that the services were pre-approved and should be covered under your dental allowance and/or remaining costs should be covered by Medicaid. The Plan denied your request. The Plan says you have exceeded your dental allowance and you are responsible for the remaining costs.  

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 the tooth extractions up to the Plan's $3,000 dental allowance.   

We looked at the file and Medicare rules. In this case the Plan provided documentation showing that the full $3,000 dental allowance has been applied towards your benefits in 2021. Therefore, we decided that the Plan does not have to provide additional payment for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for breast surgery (19330, 19371) provided on May 24, 2021.  You asked the Plan to pay for breast surgery. You say that according to your plan benefits you can go out of network. You also say that the services at issue were a medical emergency surgery. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The case record does not support that the services at issue were emergent. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for breast surgery (19330, 19371) provided on May 24, 2021.