Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified physical therapist
(G0151), services performed by a qualified occupational therapist (G0152), direct skilled nursing services of a
registered nurse (RN) (G0299), and home health care provided in the patient's home/residence (Q5001)
provided from May 22, 2021, to July 15, 2021.
You asked the Plan to pay for the services performed by a qualified physical therapist and occupational
therapist, direct skilled nursing services of a RN, and home health care provided in the patient's
home/residence. You say that you would like this claim to be reprocessed for payment. 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 also says that the RAP claim was submitted on August 4, 2021,
for the home health care period which started on May 22, 2021, and ended on July 15, 2021.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day
periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set
at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services performed by a qualified physical therapist and occupational therapist, direct skilled
nursing services of a RN, and home health care provided in the patient's home/residence have not been met.
Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date,
May 22, 2021. Therefore, we decided that the Plan does not have to pay for the services performed by a
qualified physical therapist (G0151), services performed by a qualified occupational therapist (G0152), direct
skilled nursing services of a registered nurse (RN) (G0299), and home health care provided in the patient's
home/residence (Q5001) provided from May 22, 2021, to July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) provided on August 13, 2021.
You asked the Plan to waive the coinsurance for an MRI. You say that the provider insisted you take an MRI and you used to never get billed for an MRI. The Plan denied your request. The Plan says the proper coinsurance 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 20% coinsurance for each Medicare-covered diagnostic radiology. The total amount billed was $222.17 with a coinsurance of $44.43 ($222.17 total amount x 20% coinsurance).
You have been asked to pay a 20% coinsurance for an MRI. An MRI falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for chiropractic services.
You asked the Plan to pre-approve the referral. You say that the enrollee refuses to see another chiropractor.
The Plan denied your request. The Plan says medically necessary care is available in the 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 chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been
met.
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 Synvisc. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
Plan requires a trial of Orthovisc and Supartz-FX before they will approve the requested drug. The requested
drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or
would have an adverse effect from, the Plan's preferred step-one alternatives.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Synvisc (J7325).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the vasopneumatic device therapy and vitamin injections provided on July 26, 2021.
You asked the Plan to pay for the vasopneumatic device therapy and vitamin injections. The Plan denied your request. The Plan says the Transcutaneous Electrical Nerve Stimulation (TENS) device and multivitamin injections are not covered benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vasopneumatic device therapy and vitamin injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical therapy in the State of Oklahoma.
In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does not have to pay for the vasopneumatic device therapy and vitamin injections provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that the enrollee the enrollee is too weak and frail to receive any chemotherapy and is too high risk to attempt another biopsy. The Plan denied your request. The Plan says this request does not meet clinical criteria for medical necessity.

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 Keytruda. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals were submitted for review.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for over the counter safety items provided on September 29, 2021.
You asked the Plan to reimburse you for over the counter safety items. You say that you were not aware of the Plan change to the benefit. The Plan denied your request. The Plan says effective January 1, 2021, the Plan no longer covers safety items purchased over the counter.
The Plan must follow Medicare rules. Medicare rules say that a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero direct medical cost. We looked at the file, the Medicare rules and the Plan's rules. The file shows that effective January 1, 2021, the Plan no longer covers safety items purchased over the counter. Therefore, we decided that the Plan does not have to reimburse you for over the counter safety items provided on September 29, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux.

You asked the Plan to pre-approve Erbitux. The Plan denied your request. The Plan says the drug is not being used for an approved condition.

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 Erbitux. Our physician reviewer found that the enrollee has squamous anal cell cancer. The requested use of Erbitux is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is no phase III data to support its efficacy. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary 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 Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prescription drugs provided on August 10, 2021, and September 14, 2021.
You asked the Plan to waive the coinsurance for the prescription drugs. You say that prior to signing up with the Plan you never paid for these services. You were told you had to sign up for Medicare and were told this would be covered. The Plan denied your request. The Plan says the proper coinsurance 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 20% coinsurance for each Medicare-covered Part B drug. The total amount allowed during each separate visit was $1,136.70 and the coinsurance amount of $227.34 ($1,136.70 total amount x 20% coinsurance). The total amount of coinsurance for both visits was $454.68 ($227.34 coinsurance x 2 visits).
You have been asked to pay a 20% coinsurance for the prescription drugs. The prescription drugs falls within the Medicare Part B prescription 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 prescription drugs provided on August 10, 2021, and September 14, 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 cannot tolerate or need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You will not make a significant functional progress in a reasonable period of time in an IRF. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays (D0220 and D0230), and a custom fabricated
abutment (D6057) provided by a participating provider on September 13, 2021.
You asked the Plan to pay for intraoral x-rays and a custom fabricated abutment. You say that you would like
the Plan to pay this bill. The Plan denied your request. The Plan says D6057 is not a covered benefit. The Plan
says that D0220 and D0230 has already 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. The Plan covers intraoral x-
rays once per calendar year. The Plan does not cover a custom fabricated abutment.
We looked at the file and Medicare rules. Evidence was provided to show that intraoral x-rays were provided
on August 8, 2021. Based on this information, we decided that the Plan's rules for coverage of intraoral x-rays
have already been met and a custom fabricated abutment is not a covered benefit. Therefore, we decided that
the Plan does not have to pay for intraoral x-rays (D0220 and D0230), and a custom fabricated abutment
(D6057) provided by a participating provider on September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
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 based on the medical records provided, 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. The enrollee does require physical therapy and occupational therapy services
but based on the medical records provided the patient does not require an intensive inpatient rehabilitation
therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be
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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on
August 6, 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate
diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography
(PET) scan rendered on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
December 4, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to be reimbursed
for this service. The Plan denied your request. The Plan says this service exceeds the frequency limitation in
your benefit 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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on November 25, 2020 and your comprehensive oral evaluation
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.

You asked the Plan to pre-approve the requested services. You say that the enrollee had 80% improvement following lateral branch blocks. The Plan denied your request. The Plan says the service is considered experimental and unproven.

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 services. Our physician reviewer found that the enrollee has sacroiliitis. She has tried Physical therapy and non-steroidal anti-inflammatory drugs, without lasting relief. She underwent diagnostic lateral sacral S1-S3 nerve blocks and achieved 80% pain relief. The request is for radiofrequency ablation of the lateral sacral nerves. This is considered an experimental and investigational procedure because of the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tympanostomy (tube insertion) performed on August 31, 2021.

You asked the Plan to waive the copayment for the tympanostomy. You say that there was no surgery done, just a tube insertion. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment for outpatient procedures performed in an outpatient hospital or ambulatory surgical center.

You have been asked to pay a $250 copayment for the tympanostomy. Please note that the tube insertion is considered an outpatient surgical procedure. The tympanostomy falls within the Outpatient Hospital 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 a tympanostomy (tube insertion) performed on August 31, 2021.