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

We decided that the Plan does not have to waive the deductible for the outpatient mental health care visits and emotional behavioral assessments provided from January 7, 2021 to April 6, 2021.

You asked the Plan to waive the deductible for the outpatient mental health care visits and emotional behavioral assessments. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient mental health care visits and emotional behavioral assessments on the dates of service at issue in this appeal. The Plan says that the correct amounts have applied toward your deductible per your contract with the Plan.

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 a $750 deductible which applies to Outpatient mental health care provided by an out-of-network provider. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$750 deductible which applies to Outpatient mental health care provided by an out-of-network provider. This cost sharing is a contractual obligation that had not been met at the time the outpatient mental health care visits and emotional behavioral assessments were received from January 7, 2021 to April 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient mental health care visits and emotional behavioral assessments provided from January 7, 2021 to April 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you need to start weaning off of the high flow oxygen along with consistent daily therapy which will not be provided in the hospital. The Plan denied your request. The Plan says that there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee flexion feature for the prosthetic leg.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
knee unit already comes with knee flexion as part of the knee adjustability.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

The file shows that an Otto Bock 3R60 prosthetic knee joint was requested. We looked at the file and Medicare
rules. The records show that the specific joint requested is billed using codes L5814 and L5848. These codes
were previously approved by the Plan. Based on this information, we decided that Medicare rules for coverage
of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a
knee flexion feature for the prosthetic leg.
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can receive the necessary care in another setting.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided May 18, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed as required by Medicare coding regulations.

The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. 

We find that CPT code 99153 is not supported in the medical record. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting.

Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental and investigational and therefore is not covered by Medicare.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair for the enrollee.

You asked the Plan to pre-approve the char. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a comfort/convenience item.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Paclitaxel for the enrollee.

You asked the Plan to pre-approve Paclitaxel. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that this request is not being prescribed for a medically-accepted
indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Paclitaxel. Our reviewer says that
Paclitaxel is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of Paclitaxel. Paclitaxel is not FDA-approved for the
enrollee's diagnosis. Approval for pancreatic cancer is for nab-paclitaxel (abraxane). The use of Paclitaxel is
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved
medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Paclitaxel for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services, and administration of the rabies vaccine provided April 26, 2021, to May 10, 2021.

You asked the Plan to waive the copayment for the emergency room services and administration of the rabies vaccine. You say that you were not aware you would be charged for these services. The Plan denied your request. The Plan says the cost share has processed correctly for these claims.

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 $25 copayment for specialist services and a $90 copayment for emergency room services.

You have been asked to pay a total cost share of $165 for the emergency room services and administration of the rabies vaccine ($25 copayment x 3 dates of service + $90 copayment). These services fall within the specialist 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 emergency room services, and administration of the rabies vaccine provided April 26, 2021, to May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevator identified with code E2300, towel bar assembly identified with code K0108, and back tubes identified with code K0108.

You asked the Plan to pre-approve a seat elevator, towel bar assembly, and back tubes. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that power seat elevation features (E2300) are non-covered because they are not primarily medical in nature. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that wheelchair seating cushion codes are all-inclusive.

We looked at the file and Medicare rules. Power seat elevation features (E2300) are non-covered.
The requested towel bar assembly does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Wheelchair seating cushion codes are all-inclusive. K0108 cannot be used for any component of the cushions or mounting hardware. Although these items are requested, no allowed amount is listed on the quote submitted. This means that the requested back tubes are not covered.

Based on this information, we decided that Medicare rules for coverage of a seat elevator, towel bar assembly, and back tubes have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevator identified with code E2300, towel bar assembly identified with code K0108, and back tubes identified with code K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug administration represented by code 96401 provided on May 19, 2021.

You asked the Plan to pay for code 96401. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 96401.

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 96401 is Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.

We find that CPT code 96401 is not supported in the medical record. Specifically, the record shows that the enrollee underwent an injection of Prolia to treat osteoporosis. There is a more appropriate code to describe the administration of Prolia. Based on this information, we decided that Medicare rules for coverage of code 96401 have not been met. Therefore, we decided that the Plan does not have to pay for the drug administration represented by code 96401 provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided May 13, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a clinical psychologist must meet the criteria listed in the Medicare rules. We looked at the file and Medicare rules. In this case, there was no evidence provided that the enrollee consulted to coverage before the services were provided or discussed these services with the patient's physician. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that it is imperative the enrollee starts physical therapy to help mitigate her symptoms. The Plan denied your request. The Plan says the medical care you require is provided within your network.

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 services at issue in this appeal. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from the enrollee's home who can provide the services at issue.

We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided May 29, 2021.

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.

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 has a bundled relationship with 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 (CT) scan of the head or brain coded as 70450 provided May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block 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 the prior injection gave 50-60% pain relief.

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 the enrollee did not achieve the 80% pain relief that is required to be considered a positive block. Therefore, the request is considered not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the complete lower denture (D5120)
provided on July 7, 2021.
You asked the Plan to pay the full amount for the dental service. You say that you had to fix your teeth. You
also say that you could not eat. The Plan denied your request. The Plan says there is a $1,500 allowance every
year for preventive and comprehensive dental service. The Plan also says that the annual allowance has been
exhausted.

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 and dentures are a covered service, the
annual allowance has been exhausted. The record shows that the Plan paid $90 for the oral evaluation, $150 for
the complete series x-ray, $1,030 for the upper denture, and $230 towards the complete lower denture
performed on this date of service. $90 + $150 + $1,030 + $230 = $1,500. The total charged amount of $2,795,
less the amount paid by the Plan, $1,500, is $1,295. Therefore, we decided that the Plan does not have to pay an
additional amount for the complete lower denture (D5120) provided on July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 5, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 5, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from October 5, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 5, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond October 5, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from October 5, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 5, 2021, forward
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

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 Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found Retacrit is being requested to treat anemia secondary to chronic kidney disease. The accepted use of this drug for your illness requires recent Hemoglobin (Hgb) level less than 10.0 g/dL or Hematocrit (HCT) less than 30% within the last four weeks. The documentation indicates that the enrollee had a hemoglobin of 12 on September 9, 2021. The documentation does not support that the enrollee has a hemoglobin less than 10 in the past four weeks. The requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.