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

We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physician services. You say that this doctor did your original surgery. You say that you would like to be able to see this provider again. The Plan denied your request. The Plan says there are in-network physicians available to provide these services.
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 physician services to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct admission of patient for hospital observation care
(G0379) provided on August 7, 2020.
You asked the Plan to pay for the direct admission for observation care. You say that you would like
reconsideration because the correct contracted amount has not been reimbursed. The Plan denied your request.
The Plan says per Medicare guidelines G0379 must be submitted with G0378 on the same date.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0379 is direct admission of patient for hospital
observation care.
We find that CPT code G0379 is not supported in the record. Specifically, in order to receive separate payment
for a direct referral for observation care, the claim must show both HCPCS codes G0378 and G0379 on the
same date of service. In this case, the claim does not include CPT code G0378 for the same date of service.
Based on this information, we decided that Medicare rules for coverage of the direct admission for observation
care have not been met. Therefore, we decided that the Plan does not have to pay for the direct admission of
patient for hospital observation care (G0379) provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for infrared therapy provided on September 8, 2020.
You asked the Plan to reimburse you for infrared therapy (99199). You say that this treatment was very effective on improving your neuropathy and you would like to be reimbursed for the services. Plan denied your request. The Plan says this treatment is noncovered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. This treatment was for neuropathy. Based on this information, we decided that Medicare rules for coverage of infrared therapy (99199) have not been met. Therefore, we decided that the Plan does not have to reimburse you for infrared therapy provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says there is no indication the member has had an osteoporosis-related fracture. The Plan also says that the enrollee has not tried and failed zoledronic acid.
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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the Plan requires a trial of zoledronic acid before they will approve the requested drug. The reviewer found that 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 and/or likely have adverse effects for the enrollee. The reviewer also found that the enrollee does not have a history of an osteoporosis-related fracture. Therefore, the reviewer found that Prolia cannot be approved as the step therapy criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the enrollee has not tried and failed the preferred drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite (D2335) provided on February 8, 2021, and March 10, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite. You say that you have been going to this same treating provider for years. You also say that you were not informed that the provider was not in-network at the time of service, nor were you advised that your benefits had been exceeded. The Plan denied your request. The Plan says the problem focused limited oral evaluation and first intraoral periapical x-ray are not covered services. The Plan also says that your benefits for the resin-based composite have been satisfied and the frequency limitation 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, the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) are not among those covered under this benefit. The contract says that restorations (fillings) are limited to two procedure codes per calendar year. The record shows that you received two resin-based composites on April 7, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite (D2335) provided on February 8, 2021, and March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this request is
medically necessary for your condition. The Plan denied your request. The Plan says the coverage criteria for
the requested device have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of the
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound, an urgent care visit and a
specialist visit provided from May 14, 2021, to May 21, 2021.
You asked the Plan to waive the copayments for an ultrasound, an urgent care visit and a specialist visit. You
say that you disagree with 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 $40
copayment for X-rays. Your contract with the Plan also clearly says that you must pay a $50 copayment for
urgently needed services. Your contract with the Plan also clearly says that you must pay a $45 copayment for
specialist services, including telehealth services.
You received an ultrasound on May 14, 2021. Therefore, you are responsible to pay the $40 copayment.
You had an urgent care visit on May 14, 2021. Therefore, you are responsible to pay $45, which is less than the
$50 copayment.
You had a specialist visit on May 21, 2021. Telehealth services are subject to cost-sharing charges. Therefore,
you are responsible to pay the $45 copayment.
The total amount you owe is: $130.
You have been asked to pay the total copayment amount of $130 for an ultrasound, an urgent care visit and a
specialist visit. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies
benefit category. An urgent care visit falls within the urgently needed services benefit category. A specialist
visit falls within the physician/practitioner services, including doctor's office visits 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 copayments for an ultrasound, an urgent care visit and a specialist visit
provided from May 14, 2021, to May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.

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 available from network providers.

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 referral to an out-of-network orthopedic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651).

You asked the Plan to pre-approve pneumatic compression device. You say that the enrollee has completed
four weeks of conservative therapy with no significant improvement and needs this device. The Plan denied
your request. The Plan says the denial of authorization for this device is correct, because there is no record of
conservative management following recurrence of the enrollee's lymphedema.

The Plan follows Medicare rules. Medicare rules state that a pneumatic compression device may be covered
under certain clinical conditions, including a requirement for a four-week trial of conservative 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 pneumatic compression device. Our
reviewer says that the enrollee does not meet the Medicare criteria for this PCD. Our physician reviewer found
the documentation does not show that a four-week trial of conservative therapy has been failed. There is no
evidence of failure of a regular and compliant use of an appropriate compression bandage system or
compression garment with detailed objective measurements of progress.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that
the Plan does not have to pre-approve a pneumatic compression device (E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with K3 components.
You asked the Plan to pre-approve K3 prosthetic leg. You say that a new prosthesis is being requested so the enrollee can return to K3 level ambulating. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the record does not support that the enrollee is a K3 ambulator.
The Plan follows Medicare rules. Medicare rules state that lower limb prostheses may be covered under certain clinical conditions, including an assessment of the beneficiary's rehabilitation potential. 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 K3 prosthetic leg. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested prosthesis. Our physician reviewer found the requested prosthetic items exceed the enrollee's medical need as the physician documentation does not support that this enrollee is a level K3 ambulator given the documentation that the enrollee uses a cane. Therefore, this request 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 K3 prosthetic leg have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with K3 components.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve individual psychotherapy, 60 minute sessions (90837) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the psychotherapy sessions. You say that you chose the Plan because your doctor was listed in the Provider Directory. Because this is a behavioral therapist, it is very difficult to switch to someone else after seeing him for several years. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 individual psychotherapy, 60 minute sessions (90837) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from January 11, 2021, to June 30, 2021.

You asked the Plan to waive the coinsurance for the dialysis services. You say that you believe you had met your maximum out-of-pocket prior to these services. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan has confirmed that you did not meet your out-of-pocket maximum until July 7, 2021, after these dates of service in question.

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 20% coinsurance for dialysis services. 

You have been asked to pay 20% coinsurance for the dialysis services. You did not meet your out-of-pocket maximum until after these services were rendered. 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 coinsurance for dialysis services you received from January 11, 2021, to June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional physical therapy visits, for the enrollee.
You asked the Plan to pre-approve the physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says they attempted to obtain additional clinical documentation to show continued need for physical therapy, progress made and home exercise training from the physical therapist. The Plan states they did not receive the requested documentation.
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 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy of ten (10) outpatient visits approved. The documentation does not indicate the outcome of this therapy and whether ongoing professional therapy is required. 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 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 enrollee'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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional physical therapy visits, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.

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 available from network providers.

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 referral to an out-of-network cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that currently you have various health conditions, which you wish to be evaluated. The Plan denied your request. The Plan says the certification dated August 25, 2021 documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive reticulocyte panel, whole blood (85046) provided on April 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that the testing was necessary and reasonable based upon medical necessity of the care provided and the need for treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the comprehensive reticulocyte panel, whole blood (85046) provided on April 14, 2021 by an out-of-network (OON) provider.