Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a pacemaker evaluation provided on July 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a pacemaker evaluation. You say that the services provided were medically necessary and in good faith. The Plan denied your request. The Plan says the services were provided out-of-network and 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 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 a pacemaker evaluation provided on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from March 1, 2020, through March 31, 2020.
You asked the Plan to pay for SNF care. You say that they submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request.
The Plan says the additional documentation received supports GAKE1 x 31 days & GAKE1 x 6 days. The Plan states documentation does not support the nursing CMG and NTA levels. The Plan states clinical documentation received does not support coding of asthma/COPD and malnutrition. The Plan states no documentation received showing the physician identified asthma/COPD or other chronic obstructive/restrictive lung disease as a diagnosis.
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 physician reviewer found documentation submitted was reviewed and does not meet criteria. After careful review of the documentation, a "nursing diagnosis" of Risk of Malnutrition, and intervention to prevent malnutrition is documented, however documentation does not include physician or other qualified healthcare professional diagnosis and plan of care to support the diagnosis reported. Therefore, this diagnosis should not be considered for the skilled nursing services provided during March 1, 2020, through March 31, 2020. 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 SNF care provided to the enrollee from March 1, 2020, through March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (97110) provided November 14, 2019.

You asked the Plan to pay for the therapeutic procedure. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the code is not appropriate for the service 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0157) for the billed service. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (97110) provided November 14, 2019.
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 the SNF services. You say that you need a higher level of care than just Part B therapy. You say that you need more rehabilitation so that you can go home. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy in an inpatient setting. The Plan says that there are no daily skilled nursing needs were noted. The Plan says that the enrollee's needs can be met at a lower 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, good oral intake, and clear lungs. The enrollee received physical therapy and occupational therapy. The enrollee was at a standby assist/supervision to contact guard assist level for functional mobility including gait to 125 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs may be met at a long-term care facility with part-time skilled services.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Services in the home with home health care or in a long-term care facility on a part time basis appear 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found based on the documentation provided you do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. Your care needs can be met at a lower level of care.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 26, 2021, through February 12, 2021.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says that the determination to remove secondary diagnosis code J69.0 (pneumonitis due to inhalation of food and vomit) is upheld. The Plan states that although the correspondence states this condition was "definitively documented," evidence to support this statement was not found.
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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on the diagnosis code. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 26, 2021, through February 12, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tendon sheath incision procedure you had at an outpatient hospital facility on August 4, 2021.

You asked the Plan to waive the copayment for the tendon sheath incision procedure. You say that you thought that the Plan would pay for the full cost of this surgery except for the copay. You stated that the hospital is expecting you to pay $400 even though you had prior approval for the surgery. The Plan denied your request. The Plan says the $400 you were charged reflects your copayment owed appropriately.

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 $400 copayment for outpatient surgery and other services provided at an outpatient hospital facility.

You have been asked to pay a $400 copayment for the tendon sheath incision procedure. The tendon sheath incision procedure falls within the outpatient surgery and other services provided at an outpatient hospital facility 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 tendon sheath incision procedure you had at an outpatient hospital facility on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron tablets.
You asked the Plan to pre-approve ondanestron. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Although the requested ondansetron is an oral anti-emetic, it is not being requested as a therapeutic replacement for intravenous anti-emetic drugs during chemotherapy. 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 ondansetron tablets.
Benefits for ondanestron 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (A9276, A9277, A9278).
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 no documentation stating that the current monitor is malfunctioning.
The Plan must follow Medicare rules. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes. The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. 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 a continuous glucose monitor (A9276, A9277, A9278).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on June 19, 2021, from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you did not realize this provider was out-of-network and feel that this cost is the Plan's responsibility because you did not get the referral you needed. The Plan denied your request. The Plan says hearing aids are only covered up to $1,000 when purchased from a provider in the Plan's specified hearing network. The provider in question is out-of-network, and call logs show that you ordered the hearing aids before verifying your benefits with the Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from a provider in the Plan's specified routine hearing network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified hearing vendor network.
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) purchased on June 19, 2021, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two abutment supported porcelain/ceramic crowns (D6058 x2) and a harvest of bone for use in autogenous grafting procedures (D7295).

You asked the Plan to pre-approve the abutment supported porcelain/ceramic crowns and harvest of bone for use in autogenous grafting procedures. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, 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 two abutment supported porcelain/ceramic crowns (D6058 x2) and a harvest of bone for use in autogenous grafting procedures (D7295).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomics panel provided on May 26, 2021 billed with 16 line items.
You asked the Plan to pay for the testing as billed. You say that this should be covered. The Plan denied your request. The Plan says that panels of more than one gene need to be billed with one single code.
The rules cited by the Plan do not definitively state that one code must be used to bill for genetic panel testing. As such, we find that this was not billed incorrectly and is subject to plan-directed care provisions.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the testing as billed by a contract provider. The file does not show that the plan provided notice that the testing as billed would not be covered. Under Medicare rules, this means the testing as billed is considered approved by the plan. Therefore, we decided that the Plan has to pay for the pharmacogenomics panel provided on May 26, 2021 billed with 16 line items.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation.

You asked the Plan to pre-approve the additional non-emergency transportation. You say that you were diagnosed with prostate cancer and need therapy 29 times. You also say that you are unable to drive and need to attend follow up exams and doctors' visits. The Plan denied your request. The Plan says you have exceeded the limits set in the subscriber agreement.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 42 one-way taxi or van trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on June 21, 2021.

You asked the Plan to pay for the services provided. You say that the qualifying services are billed. The Plan denied your request. The Plan says the provider did not report setup codes.

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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. We find that the services at issue were not billed with a set-up component as required. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt/recline system (E1007), a cushioned headrest (E0955) with removable headrest mount (E1028), and an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.

You asked the Plan to pre-approve a power tilt/recline system, a cushioned headrest with removable headrest mount, and an expandable controller with harness and electronic connection.

You say that the features at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of the requested features 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 a power tilt/recline system, a cushioned headrest with removable headrest mount, and an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested features are not medically necessary as the enrollee does have use of hands and can operate and control the power options using the switches that are included in the basic wheelchair. Furthermore, the documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder.

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 power tilt/recline system, a cushioned headrest with removable headrest mount, and an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a power tilt/recline system (E1007), a cushioned headrest (E0955) with removable headrest mount (E1028), and an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.