Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Myobloc for the enrollee.  

You asked the Plan to pre-approve Myobloc. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the 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 Myobloc. Our reviewer says that Myobloc is not medically reasonable and necessary for the enrollee. Based on the medical records provided the patient has not tried and failed Xeomin. There is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Myobloc.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myobloc have not been met. Therefore, we decided that the Plan does not have to pre-approve Myobloc for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission.  You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the SNF admission.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as a practical matter, you do not require transfer to a SNF. You can continue to receive care from the Inpatient Rehabilitation Facility until you are prepared for home or community discharge.    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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit provided on October 2, 2020.  You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the emergency department visit was not filed until October 8, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted multianalyte assay (81599) provided on March 30, 2021.  You asked the Plan to pay for the laboratory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate place of service code.  The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Specifically, this claim was billed with the laboratory place of service code while the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the unlisted multianalyte assay (81599) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tetanus vaccine received on September 9, 2021.  You asked the Plan to pay for the Tetanus vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus vaccine received on September 9, 2021.   Benefits for the Tetanus vaccine 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 waive the copayment for the computed tomography of the abdomen and pelvis; without contrast material (74176) provided on September 2, 2021.  You asked the Plan to waive 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 service 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 $155 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).   You have been asked to pay a $155 copayment for the Medicare-covered radiological diagnostic service provided. 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 computed tomography of the abdomen and pelvis; without contrast material (74176) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the facet joint injections (64494) provided May 13, 2021.  You asked the Plan to pay for the facet joint injections. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare billing guidelines.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. In this case, no medical records were provided to corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injections (64494) provided May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 21, 2021.  

You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.   

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist assistant in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an attendant control.  

You asked the Plan to pre-approve an attendant control. You say that this is medically necessary. The Plan denied your request. The Plan says an attendant control cannot be covered in addition to a beneficiary-operated joystick.  

The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.  

We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the enrollee-operated device control system provided with the already approved power wheelchair. Based on this information, we decided that Medicare rules for coverage of an attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thirty (30) physical therapy (PT) visits.  You asked the Plan to pre-approve PT visits. You say that the requested PT visits are medically necessary. The Plan denied your request. The Plan says the requested PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.    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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not reveal physician medical progress notes indicating a need for therapy. The enrollee is currently independent with her primary mode of transport, a manual wheelchair. She needs assistance with transfers but lives in a long-term care facility with staff that assist her. The documentation does not reveal a significant change from recent function. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve thirty (30) physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on October 1, 2021, to October 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for OON services. You say that you were not aware of any authorizations needed. The Plan denied your request. The Plan says the services were 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 file shows that you received an office visit and injection services. 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 items/services. Therefore, we decided that the Plan does not have to pay for the office visit services provided on October 1, 2021, to October 14, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist's office visit provided on September 15, 2021.  You asked the Plan to waive the copayment for a specialist's office visit. You said that the billing was incorrect. The Plan denied your request. The Plan says the billing was correct and the proper copayment was 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 $40 copayment for specialist's office visit.     You have been asked to pay a $40 copayment for a specialist's office visit. The specialist's office visit falls within the Physician/Practitioner services, including doctor's office visits 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 a specialist's office visit provided on September 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem.  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 Vertilfex device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services (99291) provided August 17, 2021 to August 18, 2021.  You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed.  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 99291 is a column II code to column I code 315000. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided August 17, 2021 to August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve admission to a SNF to be provided by an OON provider. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee for the enrollee to be transferred to.  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 admission to a skilled nursing facility (SNF) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 16, 2021 to April 18, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services provided were 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was afebrile with no signs of distress or sepsis at admission, the enrollee's other vital signs were stable; the enrollee's white blood cell elevation was modest and the enrollee's other laboratory and imaging data were unremarkable. The enrollee's failure on outpatient antibiotics was more an issue of not taking the tablets due to their size than an issue of the outpatient antibiotic being of inadequate potency. Care at the observation level appears to have been appropriate with the option to transition the patient to inpatient status if the enrollee's condition warranted further hospital level care. Therefore, the documentation does not support that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided April 16, 2021 to April 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99204) provided on August 24, 2021.  You asked the Plan to pay for an office visit. You say that you would like a retro authorization because you are not contracted with the Plan. The Plan denied your request. The Plan says the services at issue require a 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 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 an office visit (99204) provided on August 24, 2021.