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

We decided that the Plan does not have to pre-approve speech therapy services to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve speech therapy services to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Regadenoson injection 0.1 mg (J2785) provided on July 16, 2021.

You asked the Plan to waive the coinsurance for a Regadenoson injection. You say that the services should be covered as you had them rendered before with no cost sharing. The Plan denied your request. The Plan says the cost sharing applied correctly based on 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 Part B prescription drugs.

You have been asked to pay a 20% coinsurance for a Regadenoson injection (the allowed amount is $237.25, 20% of that is $47.45). Regadenoson injections fall 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 Regadenoson injection 0.1 mg (J2785) provided on July 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 6, 2021.
You asked the Plan to pay for the laboratory services. You say that the referring physician ordered specialized testing and forwarded the test directly to the provider. You say that this provider does not have direct patient contact and the claim should be adjudicated. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on June 7, 2021.

You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says there is no coverage for
services received by a provider that is not a Plan select vision provider.

Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
select vision provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses
have not been met.

Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, each additional 15 minutes (97811) provided
January 5, 2021 to April 13, 2021.
You asked the Plan to pay for the acupuncture services. You say that your insurance coverage includes
acupuncture treatments. You would appreciate review and reversal of your denial. The Plan denied your
request. The Plan says If you go to a provider who is not eligible to participate in Medicare, you will be
responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
acupuncture, each additional 15 minutes (97811) provided January 5, 2021 to April 13, 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. 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 does not meet criteria.

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 the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in-home with therapies.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the x-rays were not separated by a minimum of 90 days.

The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.

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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found there are not two sets of x-rays 90 days apart showing non-union. More time is needed.

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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3020) provided on March 16, 2021.
You asked the Plan to pay for foot orthotics. You say that you were not informed that the item at issue is not covered. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3020) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on June 7, 2021.

You asked the Plan to pay for the eyeglasses. You say that your out-of-pocket costs were triple the price at two
approved places. You say that you request reconsideration for the reimbursement of the $100 benefit. The Plan
denied your request. The Plan says there is no coverage for services received by a non-select provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are received from a select provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the eyeglasses have not been met. Specifically, the eyeglasses were purchased from a non-select
provider. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on June 7,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the shoulder you had on
August 2, 2021.
You asked the Plan to waive the copayment for the x-ray of the shoulder. You say that you were told there
would not be a separate charge for the x-ray. The Plan denied your request. The Plan says you were charged
this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for x-rays.
You have been asked to pay a $20 copayment for the x-ray of the shoulder. his 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 x-ray of the shoulder you had on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 15, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 52442 is not on the ASC addendum.
The Plan must follow Medicare rules. The rules say that under the ambulatory surgical center (ASC) payment
system, Medicare makes facility payments to ASCs only for the specific ASC covered surgical procedures on
the ASC list of covered surgical procedures.
We looked at the file and Medicare rules. Billed procedure code 52442 (cystourethroscopy, with insertion of
permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant [List
separately in addition to code for primary procedure]) is not listed on the ambulatory surgical center addendum
and is therefore not payable. Therefore, we decided that the Plan does not have to pay for the surgical services
rendered on February 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis testing provided on April 1, 2021.

You asked the Plan to pay for genetic testing. You say that this testing was ordered to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that test code 81455 will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis testing provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81551) provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you are the sole source provider for this laboratory test and therefore, cannot be performed at a contracted laboratory. You also said that since specimens for your testing are obtained during procedures, you are unable to obtain prior authorization and proactively inform patients of their individual coverage benefits for your services. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have determined that these services were not urgent or emergent, nor were they 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 laboratory services (81551) provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Insertion of mesh or other prosthesis (57267-59) provided on April 14, 2021.

You asked the Plan to pay for code 57267-59. You say that the medical records support the use of modifier 59 with code 57267. The Plan denied your request. The Plan says the medical records do not support the use of modifier 59 with code 57267.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

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 code 57267-59 Our reviewer says that the medical records do not support the use of modifier 59 with code 57267. Our physician reviewer found the enrollee is with urinary stress incontinence and a cystocele. The enrollee underwent anterior colporrhaphy and Obtryx midurethral sling placement with mesh graft.

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. 

The documentation does not support that there was a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day for the enrollee in this case. 

During the surgery, the bladder is pushed back into its normal position and the support tissue between the front of the vagina and the bladder is tightened and reinforced. The procedure is also called an anterior vaginal wall repair or anterior colporrhaphy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 57267-59 have not been met. Therefore, we decided that the Plan does not have to pay for the Insertion of mesh or other prosthesis (57267-59) provided on April 14, 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. You say that you need IRF services to return to your prior level of independent function and feel you cannot get the same results from a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.
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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home INR test meter.
You asked the Plan to pre-approve a home INR test meter. You say that the clinical information provided supports the need for the requested home INR test meter. The Plan denied your request. The Plan says the enrollee does not show to have been on a blood thinner for at least 3 months.
The Plan follows Medicare rules. Medicare rules say that an INR test meter is covered for certain clinical indications. 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 home INR test meter. Our reviewer
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has had documented atrial fibrillation and has an elevated CHADSVASC score, including the presence of hypertension and diabetes. As such, it is reasonable to treat with anticoagulation, and one such agent is warfarin, which must be monitored by periodic assessment of the INR. However, guidelines mandate a period of warfarin treatment of at least 3 months before considering authorization of an INR test meter. There is no evidence of the enrollee having received warfarin treatment for at least 3 months. As a result, at this time an INR test meter would not be considered medically reasonable and necessary in the enrollee's clinical management. 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 home INR test meter have not been met. Therefore, we decided that the Plan does not have to pre-approve a home INR test meter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure (CPT code B4152), for the enrollee.

You asked the Plan to pre-approve the Ensure. You say that the enrollee was requested to take this as patient G-tube was removed. The Plan states the service was medically necessary to supplement with Ensure protein shakes. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan under Medicare Part B.

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 Ensure have not been met. The physician has prescribed two (2) cans of Ensure a day to increase daily nutritional intake. The rules say nutritional supplements are often given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily nutritional plan. Nutritional supplementation is not covered under Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ensure (CPT code B4152), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical oncology services to be rendered by the out-of-network
provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is
not providing these services and is not making arrangements to provide these services. Therefore, we decided
that the Plan does not have to pre-approve surgical oncology services to be rendered by the out-of-network
provider.