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

We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.

You asked the Plan to pre-approve 6 home health physical therapy visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 6 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled home health physical therapy needs. The enrollee appears to be functioning at a level commiserate with a lower level of care. As such, the requested home health physical therapy is not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 there is no documentation that you require 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the requested treatment fills a treatment gap for those patients that do not receive adequate relief from traditional conservative methods and don't have instability to indicate that fusion is the appropriate treatment. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says there is not enough research to show that intraosseous rardiofrequency ablation of the basivertebral nerve improves health net outcomes in patients with vertebrogeneic back pain.
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 Intracept procedure. Our reviewer says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed oral iron. In addition, the records do not document a diagnosis of chronic kidney disease with a trial and failure of Infed and Venofer. There is no indication that the plan's preferred drugs would likely be less effective and/or likely have adverse effects. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the coinsurance for the automatic external defibrillator rental, with integrated electrocardiogram analysis (K0606) provided on September 22, 2020 and October 22, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the durable medical equipment 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 20% of the Medicare-allowed amount for durable medical equipment.
You have been asked to pay $999 ($585.12 + $413.88) for the durable medical equipment rental (DME) provided. This includes the Medicare allowed amount of $2,925.60 x 20% coinsurance=$585.12 for the DME rental purchased on September 22, 2020. Additionally, this includes a cost share of $413.88 for the DME rental purchased on October 22, 2020, which is less than the applicable coinsurance as you had met the out-of-pocket maximum for in-network medical services provided in that calendar year. 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 issue reimbursement of the coinsurance for the automatic external defibrillator rental, with integrated electrocardiogram analysis (K0606) provided on September 22, 2020 and October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on July 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 rest home visit provided on July 19, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical/thoracic facet joint radiofrequency neurolysis.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show at least two heated probe procedures on the spine joints of the neck or upper back within the past twelve months.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have not had two medial branch blocks with 80% pain relief to indicate this radiofrequency ablation. In this case, there is no documentation of the duration and percentage of pain relief from the prior right C2-C3 radiofrequency neurolysis. The review has determined that the requested procedure is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical/thoracic facet joint radiofrequency neurolysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for psychiatry.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this was denied due to the availability of qualified in-network providers who can
provide outpatient treatment.
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 psychiatry.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block with Coolief radiofrequency ablation (RFA).

You asked the Plan to pre-approve genicular nerve block with Coolief RFA. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 genicular nerve block with Coolief RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the requested genicular nerve radiofrequency ablation is 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 genicular nerve block with Coolief RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block with Coolief radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on
August 4, 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 $40 copayment for each out-of-network Medicare-covered primary care doctor visit. You have been asked to pay a $40 copayment for the out-of-network Medicare-covered primary care doctor visit 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 office visit (99213) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed (0394T) and the therapeutic radiology simulation-aided field setting (77280) provided on July 14, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services 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 20% coinsurance for Medicare-covered in-network therapeutic radiological services.
You have been asked to pay $88.75 ($55.29 + $33.46) for the Medicare-covered in-network therapeutic radiological services provided. This includes the Medicare-allowed amount of $276.45 x 20% coinsurance=$55.29 for the therapeutic radiological procedure provided. This also includes the Medicare allowed amount of $167.28 x 20% coinsurance=$33.46 for the electronic brachytherapy provided. Although the provider in this case is an out-of-network provider with the plan, the claim was processed at the in-network rate and the in-network cost share was applied. 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 high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed (0394T) and the therapeutic radiology simulation-aided field setting (77280) provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 19, 2021, to March 22, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not request a private room, so you should not be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per stay for inpatient hospital care. 

You have been asked to pay a $300 copayment per stay for an inpatient hospital admission. The same copayment is applied to private and non-private rooms. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on March 19, 2021, to March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the brain (70551) provided on June 8, 2021, at a hospital outpatient facility.

You asked the Plan to waive the copayment for an MRI scan of the brain. You say that you should not have to pay for the procedure at issue because you confirmed you were covered for the procedure beforehand. The Plan denied your request. The Plan says the correct 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 $200 copayment for Medicare-covered diagnostic radiology services (not including X-rays, mammography, or ultrasounds) when services are rendered at non-freestanding facilities.

You have been asked to pay a $200 copayment for an MRI scan of the brain. An MRI scan of the brain 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 copayment for an MRI scan of the brain (70551) provided on June 8, 2021, at a hospital outpatient facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for OneTouch Ultra test strips.

You asked the Plan to pay for OneTouch Ultra test strips. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OneTouch Ultra test strips have not been met. Specifically, the case record does not contain medical documentation to support the medical necessity of the requested items. Therefore, we decided that the Plan does not have to pay for OneTouch Ultra test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an out-of-network provider.

You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says non-emergency services provided by an out-of-network provider are not covered.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 1, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services 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. 

We find that the denied codes are not supported in this case. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a skilled nursing facility (POS 31). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member has accomplished reasonable goals of care for subacute 
rehabilitation in a nursing facility and is ready to transition to the next level of care.

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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2783) provided by an out-of-network provider on April 29, 2021.
You asked the Plan to pay for a crown. You say that this was due to your fall. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a crown (D2783) provided by an out-of-network provider on April 29, 2021.