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

We decided that the Plan does not have to pre-approve chiropractic services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says continuation of care that is failing to produce a sustainable, measurable change in the clinical status of a patient and/or designed to maintain health and well-being (such as preventative or maintenance care) has not been demonstrated in peer-reviewed literature to be effective.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has had at least 24 treatments in 2014 and that pain scores have not changed. The documentation provided does not indicate a treatment and indicates that the enrollee is receiving maintenance therapy. The elements of the coverage criteria are not satisfied. 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 chiropractic services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99335) provided on September 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that it is your position that benefits may be payable under Georgia's Managed Care Patient Protection law. Please review this denial for compliance with the above-mentioned statute. 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 domiciliary or rest home visit (99335) provided on September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072) provided on July 6, 2021, through July 13, 2021.

You asked the Plan to pay for the additional supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 99072 will be disallowed when billed in conjunction wit another CPT and/or HCPCS procedure code.

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 99072 is not supported in the record. Specifically, CPT code 99072 has a status indicator of B. This means that payment for CPT code 99072 is included in the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072) provided on July 6, 2021, through July 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit for hemodialysis (CPT code 99512), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee has end-stage kidney failure, they require hemodialysis, and the enrollee is homebound. The Plan denied your request. The Plan says renal dialysis services furnished for home dialysis are covered under the ESRD PPS and are not separately paid. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Renal dialysis services furnished for home dialysis are covered under the ESRD PPS and are not separately paid. Therefore, we decided that the Plan does not have to pre-approve home visit for hemodialysis (CPT code 99512), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided August 5, 2021.

You asked the Plan to waive the copayment for the ambulance transport and services. You say that the transport was ordered by your doctor and was not an emergency. 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 transport and services. The ambulance transport and services fall 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, emergency transport, level 1 (A0427) provided August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided on May
22, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says it is the provider's responsibility
to bill the Primary Group Health Plan or any liability insurance
before submitting the claim to the member's plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided on May 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a pacemaker evaluation (93293) provided on August 24, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a pacemaker evaluation. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 a pacemaker evaluation (93293) provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tissue substitute injection in the knee with a product called Axolotl (CPT code Q4215), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the use of Axolotl Ambient is not approved by Food & Drug Administration (FDA) for knee pain for any orthopedic condition and is also not supported in the compendia. The Plan states it is not standard of care for knee pain.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has knee pain. The requested service has not been found by the Food and Drug Administration to be safe and effective for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve a tissue substitute injection in the knee with a product called Axolotl (CPT code Q4215), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says he services can be safely received in other settings, for example: a skilled nursing facility, or home with caregiver support and home health services.
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 enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of extremity veins (93971), provided on July 16, 2021.
You asked the Plan to waive the copayment for the duplex scan of extremity veins. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says the cost share 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 $125 copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $120.40 out of the $125 copayment for the duplex scan of extremity veins. This service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the duplex scan of extremity veins (93971), provided on July 16, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve twelve additional routine transportation trips to your doctor's office.

You asked the Plan to pre-approve additional routine transportation. You say that you have multiple sclerosis and need to see your physician multiple times each month. This transportation is essential to get to your appointments. The Plan denied your request. The Plan says that your benefit only allows 30 trips for this service. You have exceeded your benefit limit. Additional trips are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 52 one-way ground transportation trips to or from locations such as network physicians, medical facilities, and pharmacies every calendar year. 

We looked at your request, the records in the case file, and the rules. The Plan has indicated that that you have used 33 routine transportation trips in 2021. The Plan says that you have exceeded your benefit limitation for this service. However, there is no documentation that the requested trips are to or from locations that would be covered by your supplemental benefits such as routine dental, vision, hearing, gym, or chiropractic services which are covered by your Plan but not by Original Medicare. There is also no documentation that the previous trips were all sed toward that portion of your routine transportation benefit. Based on the information in your appeal, it appears that you are requesting additional trips to your physician's office. You have used 33 trips at the time of appeal, and the Plan covers up to 52 one-way trips to or from network physicians.

Based on this information, we decided that the Plan's rules for coverage of additional routine transportation have been met; the benefit had not been exceeded. Therefore, we decided that the Plan has to pre-approve twelve additional routine transportation trips to your doctor's office.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective total shoulder arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient admission after surgery is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case.
Our physician reviewer found that the enrollee is a 77-year-old female with left shoulder arthritis. A request was made for inpatient services to perform a total shoulder arthroplasty procedure. The enrollee has a history of diabetes, gastroesophageal reflux disease (GERD), hypothyroidism, hypersensitivity lung disease (HLD), and hypertension (HTN). Recent notes did not reveal an unstable condition or active acute condition. The provided documentation did not suggest that the enrollee would require hospital services that would likely cross 2 midnights associated with this elective shoulder procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective total shoulder arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining self-administered drugs provided in an outpatient setting from June 14, 2021, to June 25, 2021.
You asked the Plan to pay for the remaining self-administered drugs. You say that the medication that was denied for payment was what was given to you while you were in the hospital. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs
are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the remaining self-administered drugs provided in an outpatient setting from June 14, 2021, to June 25, 2021.
Benefits for the remaining self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the transvaginal ultrasound (76830) and the ultrasound exam of the pelvis (76856) provided on July 9, 2021.
You asked the Plan to adjust 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 the copayment has been applied correctly to the services provided.
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 $175 copayment for each Medicare-covered diagnostic radiology service in an outpatient facility. If you receive multiple radiology services at the same location on the same day, only the maximum copayment applies.
You have been asked to pay a $175 copayment for the Medicare-covered diagnostic radiology services provided in an outpatient facility. 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 adjust the copayment for the transvaginal ultrasound (76830) and the ultrasound exam of the pelvis (76856) provided on July 9, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the urological supplies (A4333, A4358, A4338 and A4357) provided
on July 12, 2021.
You asked the Plan to pay for the urological supplies. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that these supplies are incidental to another
service or procedure.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the Plan has not forwarded any evidence to indicate why the requested
equipment is incidental to another service or procedure. It is the burden of the Health Plan to substantiate their
denial with evidence. In this case, the denial has not been substantiated so we must find in your favor.
Therefore, we decided that the Plan has to pay for the urological supplies (A4333, A4358, A4338 and A4357)
provided on July 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.