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

We decided that the Plan does not have to pre-approve an out-of-network referral for a lymphedema sleeve for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-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 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 an out-of-network referral for a lymphedema sleeve for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92015), provided on August 11, 2021.

You asked the Plan to pay for an eye exam. You say that the service is medically necessary. The Plan denied your request. The Plan says there are no supplemental benefits for an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtain through a network provider . 

We looked at the file and the Plan's rules. You obtained this service out-of-network. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92015), provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services you received at an outpatient hospital facility on September 10, 2021, and September 27, 2021.
You asked the Plan to waive the copayments for the lab services. You say that you believe your copayment should be $0. You said that these claims were for biopsies that your dermatologist performed, and you had no control over where your dermatology office is located or where they send labs. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for lab services at an outpatient hospital facility.
You have been asked to pay a $40 copayment for the lab services. Your contract says that if your provider bills as part of a hospital system, you may be responsible for the outpatient hospital setting cost share. The provider from whom you received these lab services bills as part of a hospital system, so the lab services fall within the lab services at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for lab services you received at an outpatient hospital facility on September 10, 2021, and September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 7, 2021 to January 14, 2021.
You asked the Plan to pay for home health services. You say that please see enclosed copy of remittance advice
as proof that this was billed before to Medicare and the copy of the eligibility for perusal. The Plan denied your
request. The Plan says the initial request for anticipated payments (RAP) claim was not received within 5
calendar days from the start of care.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the initial
request for anticipated payments (RAP) claim was not received within 5 calendar days from the start of care.
The RAP claim was not submitted until March 12, 2021 to Medicare and June 10, 2021 to the Plan. Therefore,
we decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 7, 2021 to January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing rendered on August 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 80305 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 80305 and 80307. Code 80305 is a column II code with a
modifier indicator of 1 when billed with column I code 80307. Code 80305 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
presumptive drug testing rendered on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injection services.
You asked the Plan to pre-approve Orthovisc injection services. You say that the provider does not have the
preferred products in stock in the office. The Plan denied your request. The Plan says the requested drug is a
non-preferred product.
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 Orthovisc injection services. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has
not trialed viscosupplemental treatments such as Durolane, Gelsyn-3 and Synvisc. Step therapy, as outlined by
the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons
these medications were not considered or that the Plan's required drugs would likely be less effective and/or
likely have adverse effects 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 Orthovisc injection services have not been met. Therefore, we decided that the
Plan does not have to pre-approve Orthovisc injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) and electrical stimulation (G0283) provided on August 11, 2021, to October 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for chiropractic manipulative treatment and electrical stimulation. You say that you requested an authorization and assumed it was alright to go ahead with treatment. The Plan denied your request. The Plan says it was determined that there are no records of prior authorization being obtained from the member's primary care provider for these services. The Plan also says that you must have an approval from the Plan before getting medical services or items from a specialist, an out-of-network provider, or certain other providers. The Plan also says there were in-network providers available.
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 chiropractic manipulative treatment (98940) and electrical stimulation (G0283) provided on August 11, 2021, to October 6, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Bongo expiratory positive airway pressure (EPAP)
device.
You asked the Plan to pre-approve the requested device. You say that the standard treatments for sleep apnea
do not work for the enrollee. The Plan denied your request. The Plan says the device does not meet the
definition of durable medical equipment.
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 requested device. Our physician
reviewer found that the enrollee has mild obstructive sleep apnea (OSA) and is unable to tolerate a continuous
positive airway pressure (CPAP) device.
A mandibular advancement device cannot be used because of dentures. While the Bongo device may be
beneficial in the treatment of OSA for some, there is insufficient evidence of efficacy from controlled or
comparison studies. Therefore, the Bongo expiratory positive pressure device is considered not medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Bongo expiratory positive airway pressure (EPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.

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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no intravenous medications and no complex wound care. Daily skilled services are not required. You are walking 200 feet with a front-wheeled walker with stand-by assistance, and you are contact guard assist for transfers and contact guard to minimum assist for activities of daily living. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you do not
have a need for prolonged postoperative monitoring.
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.
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 services. Our physician
reviewer found that you presented to the hospital with an ankle fracture, which required surgical intervention.
Your medical conditions were otherwise stable. Your blood pressure, pulse, and oximetry were within normal
limits. Your provider did not document the need for complex care or monitoring either preoperatively or
postoperatively. The record did not show that your necessary hospital care would span two midnights.
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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve acute inpatient hospital services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on July 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on July 27, 2021 by an out-of-network (OON) provider.
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 reasonable and necessary for your condition. The Plan denied your request. The Plan says rules for IRF care have 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 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 you were admitted for surgical repair of a hip fracture after a fall. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the injection services (A4550, J0585, 64615, 99213) provided on May
5, 2021.

You asked the Plan to pay for the injection services. You say that you believe these services should be covered.
The Plan denied your request. The Plan says that payment cannot be made before an explanation of benefits is
received from the primary insurance payor.

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 not met its obligation with regards to coordination of benefits. Specifically, there is no evidence
that the Plan has sent the bill directly to the primary insurer, directed the provider to send the bill to the primary
insurer, or paid for the services and requested reimbursement. Specifically, the documentation indicates that the
Plan "tried to obtain the Explanation of Benefit." This action does not satisfy Medicare's coordination of
benefits requirements. Therefore, we decided that the Plan has to pay for the injection services (A4550, J0585,
64615, 99213) provided on May 5, 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.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve continued outpatient mental health care with an out-of-network provider.
You asked the Plan to pre-approve outpatient mental health care. You say that you have been seeing this provider since 1989, and his location and licensure have not changed since you enrolled in this plan. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and is not licensed in the state in which you reside.
The Plan must follow Medicare rules. Medicare rules say that covered clinical social worker services include services that the clinical social worker (CSW) is legally authorized to perform under State law of the State in which such services are performed. Your contract with the Plan says that you may choose to receive care from an out-of-network clinical social worker. We looked at the file and Medicare rules. The requested services are covered by Medicare because the clinical social worker you want to see is licensed in the State of Colorado, where the provider is located, and as a result is legally authorized to perform such service under Colorado State law. Additionally, your contract with the Plan includes coverage for out-of-network outpatient mental health care services. You may choose to continue seeing this provider using your Plan's out-of-network benefits. Based on this information, we decided that Medicare rules for coverage of outpatient mental health care have been met. Therefore, we decided that the Plan has to pre-approve continued outpatient mental health care with an out-of-network provider.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extraction (D7210) provided on September 9, 2021.

You asked the Plan to reimburse you for the dental services. You say that you did not know that you were being sent to a dentist that was not covered by Medicare. You also say that you were in pain and had to get a tooth extracted as soon as possible. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that reimbursement will not be made for services performed by a provider that has opted out of Medicare.

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, dental services performed by a provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extraction (D7210) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on
September 27, 2021.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that the approval letter for this
drug did not mention any copayment. You said that you were unaware of this coinsurance. The Plan denied
your request. The Plan says it has removed the copayment charged for the administration service. You are only
being charged the coinsurance for the drug itself. The Plan says that you were charged this coinsurance
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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the
Medicare Part B drugs 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 coinsurance for the Prolia injection you received on September
27, 2021.