Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on July 14, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the rendering physician and facility are also out-of-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 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 physical therapy provided on July 14, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve twelve (12) additional physical therapy visits.  You asked the Plan to pre-approve twelve (12) additional physical therapy visits. You say that additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says that additional physical therapy visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted the required medical records for us as we requested. Therefore, we decided that the Plan has to pre-approve twelve (12) additional physical therapy visits.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by physical therapy assistant on July 6, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. 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 records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by physical therapy assistant on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 10, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from December 10, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from December 10, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 10, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 10, 2021, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from December 10, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 10, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for outpatient surgery you had at an outpatient hospital facility on July 26, 2021, to July 27, 2021.
You asked the Plan to reduce the coinsurance for the outpatient surgery. You say that you were told that if you spent the night in the hospital, your copayment would only be $395. You said that you spent the night overnight. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you had an observation stay overnight, but you were never admitted as an inpatient to the hospital.
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 outpatient surgery. You have been asked to pay 20% coinsurance for the outpatient surgery. Your contract says that unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. That was the case here- you were never admitted as an inpatient to the hospital, so this is considered outpatient surgery. 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 reduce the coinsurance for outpatient surgery you had at an outpatient hospital facility on July 26, 2021, to July 27, 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. The Plan denied your request. The Plan says the enrollee does not need a team of providers.  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 physician reviewer found that you are medically stable except for dizziness with orthostasis. There are no other current acute medical problems. You do not require a rehabilitation physician's supervision three times a week, and you have no acute nursing needs. Based on your current high level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.  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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on March 12, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Per Medicare guidelines this code is not a valid code for Medicare purposes as CPT code(s): S1015 and S8301 are assigned a status code I = Not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on August 6, 2021.  You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.  We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation shows that this service was reported within 90 days of the major surgical procedure, 33249 (Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber), which was billed on August 5, 2021. This provider of the surgical procedure and the provider of this subsequent hospital care service are within the same group and have the same specialty. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing (CPT code(s): 81292 and 81321) provided to the enrollee on June 21, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee had molecular cancer genomics (CGx) testing on June 21, 2021. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing (CPT code(s): 81292 and 81321) provided to the enrollee on June 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that this is the provider that you trust the most. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can receive physical therapy from an in-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 physical therapy to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically
ill or critically injured patient; each additional 30 minutes (CPT code 99292 (4 units)) provided to the enrollee
from June 1, 2021, through June 2, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code 99292 (4 Units) remains not supported. The submitted medical records include critical care note and
time; however, do not support the 4 units billed. Therefore, the billed CPT code cannot be verified. The
documentation submitted did not support a critical care visit of an additional 30 minutes of critical care time in
addition to the first 30-74 minutes of a critical care evaluation and management service CPT code 99291) for
this date of service. 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 the critical care, evaluation and
management of the critically ill or critically injured patient; each additional 30 minutes (CPT code 99292 (4
units)) provided to the enrollee from June 1, 2021, through June 2,2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
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 that you have completed your intensive course of care at the inpatient
rehab facility and intermittent therapy can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that that the Plan has denied your request based on medical necessity.
However, the Plan has not provided any medical records for review. Without medical records, we are unable to
substantiate the Plan's denial rationale. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of the colon, malignant neoplasm of unspecified ovary, and osteoporosis. She has not tried and failed the Plan's required drugs, intravenous (IV) pamidronate or zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; therefore, Xgeva is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these supplies are covered under the Soft Goods section. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Prolia. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a
new start. The provided records do not support that the enrollee is currently receiving the requested medication.
The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one
alternative. 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 alternative. Therefore, the enrollee does not meet criteria for the
requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy (97165) provided
on June 25, 2021.
You asked the Plan to waive the copayment for the occupational therapy. You say that you had this therapy on
the same day as an appointment with a physician, and you did not expect to pay for both services. You also say
you saw both the physician and the occupational therapist on the 21st. The Plan denied your request. The Plan
says the claim was processed correctly, and your cost-sharing was assessed in accordance with your contract.
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 $35
copayment for each day of Medicare-covered occupational therapy services. If you receive services outside of
the benefit described, an additional cost share may apply.
You have been asked to pay a $35 copayment for the occupational therapy. You say that you paid the
copayment for the office visit with your physician, and you say that the occupational therapy was provided on
the same day as part of the same appointment. The date on the medical records submitted reflects June 25,
2021, but even if both services were rendered on June 21, 2021, both copayments still apply. The occupational
therapy is a service that is not part of a typical physician visit, and these services were rendered by two separate
individuals. 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 occupational therapy (97165) provided
on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx for Prostate Cancer (CPT code 81479) provided
to the enrollee on May 17, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. SelectMDx in males with previous
negative prostate biopsy who are being considered for repeat biopsy is promising with evidence of some
clinical utility to reduce unnecessary repeat prostate biopsies. There was no documented result of prior prostate
biopsy. There was no documented significant interval increase in PSA level. Therefore, we decided that the
Plan does not have to pay for SelectMDx for Prostate Cancer (CPT code 81479) provided to the enrollee on
May 17, 2021.