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

We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.
You asked the Plan to pre-approve office visits. You say that you would like to continue to receive care from
the OON provider you have seen in the past. The Plan denied your request. The Plan says they have in-network
providers available to provide the care you need.
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
office visits to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that you have trouble with balance and the requested item will help prevent falls. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Prolia.
You asked the Plan to pre-approve a tier exception for Prolia. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighteen additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says a home exercise program should help the goals be reached.

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 the additional 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 additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy approved and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You should be able to transition to a home exercise program with the already authorized extensive therapy. The requested services are not part of a maintenance program. 

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eighteen additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the positive airway pressure (PAP) supplies and accessories.
You asked the Plan to pre-approve the PAP supplies and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says your records show that you have been using your CPAP since August 6, 2021. However, your records fail to show that you have used your CPAP greater than 4 (four) hours per night for 30 consecutive days.
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PAP supplies and accessories have not been met. Specifically, you have not used Therefore, we decided that the Plan does not have to pre-approve the positive airway pressure (PAP) supplies and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 13, 2021.
You asked the Plan to pay for the services. 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 requested 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 services provided by an out-of-network provider on April 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded as 97110 provided March 27, 2021.
You asked the Plan to pay for the therapeutic procedure coded as 97110. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there is a more appropriate code to bill for the services provided.
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 asked our coder 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 the therapeutic procedure coded as 97110. Our reviewer says that the criteria for coverage have not been met. Our reviewer found the documentation submitted includes a Physical Therapy visit was performed in the home. There is a more specific code to report for therapy in the home setting. Therefore, CPT 97110 would not be covered in this case. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure coded as 97110 have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded as 97110 provided March 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 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 services provided by an out-of-network provider on May 20, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the insertion of a central venous catheter provided on April 28, 2021.
You asked the Plan to waive the copayment for the insertion of a central venous catheter. You say that you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being 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 $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the insertion of a central venous catheter on April 28, 2021, at an outpatient hospital facility. The insertion of a central venous catheter is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $175 copayment. You have been asked to pay a $175 copayment for the insertion of a central venous catheter. The insertion of a central venous catheter falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the insertion of a central venous catheter provided on April 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy provided on May 27, 2021.
You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the claim should be reprocessed. The Plan denied your request. The Plan says payment for this service is bundled with the other procedure codes 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, the CPT Code Manual definition of code 97010 is application of a modality to 1 or more areas; hot or cold packs.
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day management services (99239) provided on January 28, 2020.
You asked the Plan to pay for the discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that more than 30 minutes of discharge say management services were performed.
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 99239 is hospital discharge day management; more than 30 minutes We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not
show that more than 30 minutes of hospital discharge day management services were rendered on the billed date of service. CPT 99239 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management services (99239) provided on January 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission and service provided from March 23, 2021, to April 21, 2021.
You asked the Plan to pay for SNF care. You say that these services were medically necessary and should be covered by the Plan. The Plan denied your request. The Plan says the SNF care was not medically necessary for this enrollee at the time of service.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no identifiable skilled nursing service or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. These services were 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission and service provided from March 23, 2021, to April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
You asked the Plan to pre-approve the ventilator. You say that you are asking for a fast appeal of this decision. You have attached supporting documentation for review. The Plan denied your request. The Plan says the request for a portable ventilator does not meet the Medicare criteria. You may meet the criteria for a different type of breathing machine.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
In this case, the requested device is being used in a bilevel PAP mode that could be provided with a BiPap (E0421) device with AVAPS added to assure adequate tidal volumes. Medicare does not cover ventilators used in this way. The plan says that E0471 would be approved upon request. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on June 1, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you were told that you would not owe a copayment because you were receiving continued care from your visit the day before. The Plan denied your request. The Plan says the claims were processed correctly and you are being 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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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
urgently needed services provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on April 1, 2021.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never had to pay coinsurance for your ostomy supplies before. The Plan denied your request. The Plan says 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 prosthetic devices and related supplies. You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the prosthetic devices and related 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 ostomy supplies you received on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital 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 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found recent notes did not suggest the enrollee required hospital services that would likely cross 2 midnights for this lower risk procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the target genomic sequencing laboratory testing provided on March 7, 2021.
You asked the Plan to pay for the target genomic sequencing laboratory testing. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as
billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
Review of the file shows that the Plan uses Local Coverage Article (LCA) A56518 to support their denial.
However, LCA A56518 is not valid for the provider's billing state of Texas. Therefore, we are unable to use
LCA A56518 to substantiate our decision.
There is no documentation to support that the target genomic sequencing laboratory testing at issue in this
appeal was not requested solely for screening purposes. Medicare does not cover this test solely for screening
purposes. Therefore, we decided that the Plan does not have to pay for the target genomic sequencing
laboratory testing provided on March 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an endosteal implant (D6010 x 15).
You asked the Plan to pre-approve the dental service. You say that the services are necessary. You say that the implants will secure your denture to your gums so that you can chew food again. You also say that having to go through these services are essential to improve your overall dental condition. The Plan denied your request. The Plan says surgical placement of endosteal implant is not listed as a covered service.
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 endosteal implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of an endosteal implant (D6010 x 15).