Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the osteogenesis stimulator (E0747) 
provided April 30, 2021. 
 
You asked the Plan to waive the copayment for the osteogenesis stimulator. You say that you were advised that 
since you had both Medicare and the Plan your cost would only be $150.00 The Plan denied your request. The 
Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
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 15% of 
the total cost for Medicare covered DME items. 

You have been asked to pay $534.20 (the allowed amount of $3,561.31 x 15%) for the osteogenesis stimulator. 
The osteogenesis stimulator falls within the Durable medical equipment (DME) 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 copayment for the osteogenesis stimulator (E0747) provided 
April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided
June 19, 2020.

You asked the Plan to pay for the chiropractic services. You say that you have had checks issued to the doctor
that should have been issued to the facility. You have been told numerous times that these checks will be
reissued to the correct payor. The Plan denied your request. The Plan says the claim was reprocessed however
payment is not allowed for this service because the procedure code billed is missing the required modifier.

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 98941 is chiropractic manipulative treatment, spinal, 3-4
regions.

We find that CPT code 98941 is not supported in the medical record. Specifically, the claim was reported
without an appropriate modifier. Chiropractic manipulative treatment claims without the AT, GA, GX, GY or
GZ modifiers will be considered as maintenance therapy and denied. Based on this information, we decided
that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the
Plan does not have to pay for the chiropractic manipulative treatment (98941) provided June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the compounded drug (J7999) provided on January 28, 2021.

You asked the Plan to waive the coinsurance for the compounded drug (J7999). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a Part B drug on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 Part B prescription drugs. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a compounded drug (J7999) on January 28, 2021. You have been asked to pay a 20% coinsurance for the compounded drug (J7999), totaling $46.40. The compounded drug (J7999) 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 the compounded drug (J7999) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve Abraxane. You say that you feel this drug is medically necessary for the
enrollee. The Plan denied your request. The Plan says the requested services are not payable.
The Plan must follow Medicare rules. Medicare rules say that Original Medicare covers services related to the
routine costs of clinical trials.
We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical
trial. The requested drug is related to the clinical trial the enrollee is enrolled in. This means that the Plan is not
responsible for pre-approval of this drug. Based on this information, we decided that Medicare rules for
coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve
Abraxane
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostheses to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve prostheses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.
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 prostheses to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3310) for tooth #25.
You asked the Plan to pre-approve a root canal. You say that you are in pain, and this service is necessary. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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. Endodontics are not covered by the Plan's dental benefit. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3310) for tooth #25.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on April 27, 2021.

You asked the Plan to pay for occupational therapy services. You say that the documents should be reviewed,
and the claim processed toward payment. The Plan denied your request. The Plan says the records do not
support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services
incident to a physician/non-physician practitioner's service must meet all incident requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of occupational therapy services have not been met. Specifically, the billing provider is a physician
assistant, and not a licensed therapist. As such, OT services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy
services provided by an occupational therapist on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not demonstrated significant improvement in osteoarthritis pain, compared with immediate-release formulation of triamcinolone acetonide.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 injection. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found Zilretta (extended-release triamcinolone acetonide injectable suspension) is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. However, it is not medically necessary because it has not demonstrated a significant improvement in osteoarthritis pain compared with the immediate-release formulation of triamcinolone acetonide. The review has determined that Zilretta 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Zilretta injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. You say that you are currently at a skilled nursing facility and feel your complete recovery will be affected if you cannot get inpatient rehabilitation at an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your skilled therapy needs may be continued at the skilled nursing facility level or at home if requested.

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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that this should be approved as it prevents respiratory infection. The Plan denied your request. The Plan says the criteria is not met.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 a HFCWOD. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the enrollee has COPD and pulmonary fibrosis, but does not have a diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. This device has not been demonstrated to be effective in the treatment of COPD or idiopathic pulmonary fibrosis (IPF). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick.

You asked the Plan to pre-approve Repatha SureClick. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick.

Benefits for Repatha SureClick 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 3) and periapical x-ray (D0220) provided on June 17, 2021.

You asked the Plan to pay for the dental services. You say that you had to have 3 teeth pulled as soon as possible. You also say that your handbook says that 2 extractions are covered per year. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network 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 and the services are listed as covered, dental services you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7140 x 3) and periapical x-ray (D0220) provided on June 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy re-evaluation provided on May 6, 2021.
You asked the Plan to pay for the physical therapy re-evaluation. You say that the Plan is required to pay noncontracted
providers at the preferred rate if the services are not available from preferred providers. You say that
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request.
The Plan says the claim was not billed with the proper modifier.
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 CPT code 97164 is not supported in the medical record. Specifically, CPT code 97164 is
considered a therapy code. This means that CPT code 97164 requires a therapy modifier of GN, GO or GP. The
claim shows that CPT code 97164 was not billed with a required therapy modifier. Based on this information,
we decided that Medicare rules for coverage of the physical therapy re-evaluation have not been met.
Therefore, we decided that the Plan does not have to pay for the physical therapy re-evaluation provided on
May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist visits (99213) provided from
May 20, 2021, to June 8, 2021.
You asked the Plan to waive the copayments for the specialist visits. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says you received services provided by a
specialist on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied
per your contract with the Plan.
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 per specialist visit.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received specialist visits
from May 20, 2021, to June 8, 2021. You have been asked to pay a $40 copayment for each of the specialist
visits, totaling $160. The specialist visits fall within the Physician/Practitioner services benefit category. This
means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayments for the specialist visits (99213) provided from May 20, 2021,
to June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint nerve ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is not enough medical evidence to show that this procedure is safe and effective.

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 according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.
Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed
radiofrequency, is considered investigational and therefore, not medically necessary. The review has
determined that the service at issue in this case are 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 sacroiliac joint nerve ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that going to skilled nursing will get you the care you need for your lungs. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.

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 your condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services.
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 you have issues with balance and mobility and are a fall risk. You feel that inpatient rehabilitation is medically necessary for your full recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.