Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 25, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nine surgical extractions (D7210 x9) provided on August 20, 2021.  You asked the Plan to pay for the surgical extractions. You say that prior to receiving the extractions you contacted the Plan and were led to believe your insurance would pay a major portion of this procedure. The Plan denied your request. The Plan says this is not a covered service under your plan.  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 requested items or services are not among those covered under this benefit. The only type of extractions that are covered by the Plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the nine surgical extractions (D7210 x9) provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in home with intermittent therapies or placement in a skilled nursing facility with intermittent therapies.  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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on May 21, 2021.  You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.  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 outpatient rehabilitation services/in-network/physical therapy.   You have been asked to pay a $25 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation services/in-network/physical therapy 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 physical therapy provided by a participating provider on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) rendered on August 21, 2020.  You asked the Plan to waive the copayment for an office visit with a specialist. You say that you were an inpatient of a hospital and it was out of your control regarding who and what was going on with the hospital procedures. The Plan denied your request. The Plan says you were 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 $35 copayment for Medicare-covered specialist services.   You have been asked to pay a $35 copayment for an office visit with a specialist. 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 office visit with a specialist (99213) rendered on August 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity (J3111).  You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your request. The Plan says a trial of Forteo or Tymlos is required before alternatives can be considered.    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 Evenity. Our reviewer says that Evenity is not medically necessary. Our physician reviewer found the record shows no trial of the plan's preferred drugs or any reason they would be unsafe or ineffective for this 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received from July 22, 2021, to July 26, 2021.  You asked the Plan to waive the copayment for the ER services. You say that you were following medical instructions to go to the ER, so this should be paid in full. The Plan denied your request. The Plan says this claim was not denied.  Rather, you were assessed the appropriate cost sharing for these services.  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 $90 copayment for emergency room services.   You have been asked to pay a $90 copayment for the ER services. 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 emergency room (ER) services you received from July 22, 2021, to July 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for nursing facility discharge day management services provided on February 19, 2021.  You asked the Plan to pay for nursing facility discharge day management services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for nursing facility discharge day management services provided on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 was medically stable after a wrist fracture with no evidence of need for supervision by a physical, medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and lack of medical complexity. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (L0650, L1851, L1971, L2397, L3170, L3916, and L3960).
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L0650, L1851, L1971, L2397, L3170, L3916, and L3960).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a physician visit provided to the enrollee on August 11, 2021.  You asked the Plan to pay for the services. You say that this should be covered by the plan. The Plan denied your request. The Plan says the services were not urgent or emergent, and were not 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 a physician visit provided to the enrollee on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injection (a second diagnostic medial branch block (MBB)).  You asked the Plan to pre-approve facet joint injection. You say that you are non-mobile due to the back pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because your first diagnostic medial branch block did not provide more than 80% pain relief.  The Plan follows Medicare rules. Medicare rules state that a second diagnostic facet joint injection is covered when the first diagnostic injection provided at least 80% pain relief.  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 facet joint injection. Our reviewer says that you do not meet the Medicare criteria for the requested facet joint interventions. Our physician reviewer found the records do not document that prior facet joint injections provided 80% relief of your primary pain as required by Medicare rules.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection (a second diagnostic medial branch block (MBB)).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health care to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve home health care. You say that you are aware that this provider is out-of-network and request that the Plan authorize home physical therapy with this provider. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan, and you can be treated by an in-network home health agency.  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 home health care to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided on November 16, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  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. In this case, the Plan denied payment for the laboratory services provided on November 16, 2020 stating medical records amended for the purpose of gaining reimbursement cannot be accepted. However, the Plan provided no evidence that the records provided in the case file were amended in any way. We find that the Plan has not substantiated their reasoning for the denial of payment for these services. Therefore, we decided that the Plan has to pay for the laboratory services provided on November 16, 2020.   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 pay for inpatient services provided from July 28, 2020, through  July 30, 2020 with the reported secondary diagnosis, J96.01, acute respiratory failure with hypoxia.  You asked the Plan to pay for inpatient services provided from July 28, 2020, through July 30, 2020 with the reported secondary diagnosis, J96.01, acute respiratory failure with hypoxia. The Plan denied your request. The Plan says according to coding guidelines and documentation in the medical record this condition did not qualify for reporting.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with the secondary diagnosis, J96.01, acute respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services with the reported secondary diagnosis, J96.01, acute respiratory failure with hypoxia. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the review indicates that the enrollee had endobronchial bleeding after a bronchoscopy and biopsy. She had no history of lung disease. She initially required intubation for airway protection. Upon extubation she required a maximum of 4 liters of oxygen. There was no requirement of oxygen > 5 liters or use of BIPAP. There was no documentation of respiratory failure. The review has determined that the secondary diagnosis, J96.01 , acute respiratory failure with hypoxia, was not supported by the medical records.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from July 28, 2020, through July 30, 2020 with the reported secondary diagnosis, J96.01, acute respiratory failure with hypoxia.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on June 9, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on June 9, 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 the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee has no daily skilled nursing or therapist needs.  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 the SNF services. 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 shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.