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

We decided that the Plan does not have to pay for new patient domiciliary or rest home visit (99326) provided on May 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that kindly review and reprocess the claims and reimburse for services rendered in good faith best interest to the enrollee. 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 new patient domiciliary or rest home visit (99326) provided on May 7, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT code(s): 97012, 98941, 97110) provided to the enrollee on April 14, 2021, by an out-of-network provider.
You asked the Plan to pay for the chiropractic services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 chiropractic services (CPT code(s): 97012, 98941, 97110) provided to the enrollee on April 14, 2021, by an out-of-network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found percutaneous discectomy is experimental. More research 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc first.
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 Durolane. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation provided, the enrollee is noted to have bilateral knee osteoarthritis. A request has been made for Durolane, a hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of hyaluronic acid be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery service on February 23, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that your service was approved. The Plan denied your request. The Plan says the copayment applied was correct.

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 outpatient surgery performed in an outpatient hospital setting. 

You have been asked to pay a $250 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, 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 outpatient surgery service on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 22, 2021 by an out-of-network provider.
You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an established patient (99336). You say that it was the facility's responsibility to obtain authorization. The Plan denied your request. The Plan says a valid authorization was not requested or in effect on the date of service.
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 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 the service. Therefore, we decided that the Plan does not have to pay for physician services provided on March 22, 2021 by an out-of-network provider
Appeal type: Drugs
Decision: Partially Favorable

You asked the Plan to waive the coinsurance for Part B drug. You say that you are on a fixed income, but critically need this medicine. The Plan says that the coinsurance amount you are being charged is correct.
We decided that the Plan has to reduce the coinsurance amount for Part B drug.
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 says that you must pay 20% coinsurance for Medicare Part B prescription drugs. The allowed amount of this claim is $137.36, resulting in a coinsurance amount of $27.47.
The Plan says that you must pay $137.36, which is 100% coinsurance for Part B drug. According to your contract with the Plan, however, you cannot be asked to pay more than $27.47, which is 20% coinsurance for Part B drug. Therefore, we decided that the Plan has to reduce the coinsurance amount for Part B drug from $137.36 to $27.47.
We also decided that the Plan does not have to waive the coinsurance for Part B drug.
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 Part B drug. The allowed amount of the claim is $137.36, resulting in a coinsurance amount of $27.47. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drug.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Group 3 Power Wheelchair.

You asked the Plan to preapprove the power wheelchair. You say that the wheelchair and components are necessary. The Plan denied your request. The Plan says the clinical documentation provided and reviewed and does not show that the member's mobility limitation is due to a progressive neurological condition, myopathy, or congenital skeletal deformity.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity. 

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to preapprove a Group 3 Power Wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient domiciliary, rest home visit (99336) provided on May 3, 2021 to May 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visit. You say that you would like to appeal for retroactive authorization based on medical necessity. 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 established patient domiciliary, rest home visit (99336) provided on May 3, 2021 to May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implants (D6010) for teeth #12, 18, and 20
provided from February 27, 2021, to March 31, 2021.
You asked the Plan to pay for the dental services. You say that you do not agree with the denial. You also say
that the services should be covered. The Plan denied your request. The Plan says the implants for fixed
abutments of crowns and bridges are excluded from coverage.
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, implants for fixed abutments of crowns
and bridge are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the endosteal implants (D6010) for teeth #12, 18, and 20 provided from February 27, 2021, to March
31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 have a past medical history of Parkinson's disease and dementia and is living at home with ongoing weakness. 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on May 11, 2021.

You asked the Plan to pay for the ambulance transportation. You say that this transportation was medically necessary and should be paid. The Plan denied your request. The Plan says the member was an inpatient at the time of this transportation, and therefore these services were covered with the payment of the inpatient care.

The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service. 

We looked at the file and Medicare rules. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider. The record also shows that the enrollee was provided with an inter-facility transfer while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on May 7, 2021.

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 drug testing (80307) rendered by the out-of-network (OON) provider on May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on April 14, 2021.
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 70450 for the computed tomography 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 coded 70450 provided on April 14, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for genicular nerve injections (64454, Q9966) provided on May 5, 2021.
You asked the Plan to pay for genicular nerve injections. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered for the enrollee's diagnosis.
The Plan must follow Medicare rules. Medicare rules say that coverage for CPT codes 64400, 64405, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, 64449, 64454 and 64624 is limited to certain diagnosis codes. Diagnosis M17.0 is not listed as a covered diagnosis. We looked at the file and Medicare rules. The billed diagnosis does not support the billed services. Based on this information, we decided that Medicare rules for coverage of genicular nerve injections have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve injections (64454, Q9966) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) and addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).
You asked the Plan to pre-approve these items. You say that you are unable to walk without the prosthetic leg. The Plan denied your request. The Plan says that the requested microprocessor knee exceeds your need.
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 items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Your medical provider does document that you have the potential to be a K3 level ambulator, however the prescribing provider does not document the need for a microprocessor knee over a mechanical K3 knee. Our physician reviewer found that your condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) and addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).