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

We decided that the Plan does not have to pre-approve Verquvo 5 mg tablet.

You asked the Plan to pre-approve Verquvo. You say that this is medically reasonable and necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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 Verquvo 5 mg tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unspecified preventative procedure, by report (D1999) provided July 3, 2021.  You asked the Plan to pay for the personal protective equipment (PPE). You say that your crown was approved. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 pay for the unspecified preventative procedure, by report (D1999) provided July 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an outpatient surgery
provided by a participating provider August 10, 2020.
You asked the Plan to waive the deductible and copayment for an outpatient surgery. You say that you do not
agree with this bill. The Plan denied your request. The Plan says the correct copayment and deductible has been
applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $1,000 deductible and a $250 copayment for outpatient surgery/in-network/outpatient surgery.
The enrollee has been asked to pay a $1,000 deductible and a $250 copayment for an outpatient surgery. The
total amount you are being asked to pay is $1,250 ($1,000 + $250 = $1,250). An outpatient surgery falls within
the outpatient surgery/in-network/outpatient surgery benefit category. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the deductible and copayment for an outpatient surgery provided by a participating provider
August 10, 2020.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the copayment for emergency room services provided on June 24, 2021.  You asked the Plan to waive the copayment for emergency room services. You say that you were told you were admitted as an inpatient. You say the emergency room copayment should be waived. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.  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 did not provide supporting medical records showing what services were received or whether you had been admitted as an inpatient or not. Therefore, we decided that the Plan has to waive the copayment for emergency room services provided on June 24, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 4, 2021.  You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment, and if it is covered the payment for it is subsumed by the patient for the service to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from June 23, 2021, to September 9, 2021.  You asked the Plan to waive the copayments for the physical therapy visits. You say that your patient responsibility shows various amounts for outpatient therapy.  The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. You would like the Plan to review and advise on the cost-sharing.  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 day for in-network Medicare-covered physical therapy services.   You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 18 visits = $720). The physical therapy visits fall within the "Outpatient rehabilitation services" 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 copayments for the physical therapy visits provided from June 23, 2021, to September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tub stool.  You asked the Plan to pre-approve a tub stool. You say that you are unable to bathe or shower and that the stool is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a tub stool may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub stool.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the myocardial perfusion imaging (SPECT) you had on February 11, 2021, and the transthoracic echocardiography (TTE) you had on March 17, 2021.  You asked the Plan to waive the copayments for the SPECT and the TTE. You say that you were told that if you had these tests off-campus or in a doctor's office that you would pay nothing for them. You said that these tests were performed in the doctor's office. The Plan denied your request. The Plan says these copayments were charged 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 $235 copayment each for diagnostic procedures or tests at an outpatient facility.   Records show that the location where you received these services bills as an outpatient hospital facility. You have been asked to pay a $235 copayment each for the SPECT and the TTE. The SPECT and the TTE fall within the diagnostic procedures or tests at an outpatient 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 copayments for the myocardial perfusion imaging (SPECT) you had on February 11, 2021, and the transthoracic echocardiography (TTE) you had on March 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided from January 28, 2021, through February 18, 2021.  You asked the Plan to pay for the home health services. You say that this was medically necessary home health care which should be reimbursed. The Plan denied your request. The Plan says an invalid Q-code was reported on this claim. A corrected claim must be submitted.  The Plan must follow Medicare rules. Medicare rules say that home health agencies are required to report the location at which a patient receives home health care by reporting a line item with Q5001, Q5002, or Q5009.      In this case, the claim was billed with a line item reporting code Q5010. This is not a valid code for the Medicare home health prospective payment system. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 28, 2021, through February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided from March 6, 2020, through March 14, 2020.  You asked the Plan to pay for the home health services. You say that the medical records support that payment should be made for this claim. The Plan denied your request. The Plan says no payment can be made as no RAP was received for this episode of care.  The Plan must follow Medicare rules. Medicare rules say that payment is made for home health services in two parts. The first part is made when a RAP is submitted.   In this case, the file shows that no RAP was submitted for this episode of care before submission of the final claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from March 6, 2020, through March 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the COVID-19 testing provided on May 25, 2021, billed with codes U0003 and U0005.  You asked the Plan to pay for the COVID-19 testing. You say that this was not related to hospice and should be covered by the Plan. The Plan denied your request. The Plan says when an enrollee elects hospice, all Medicare-covered services are paid either through the hospice or the Original Medicare contractor.  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 COVID-19 testing provided on May 25, 2021, billed with codes U0003 and U0005.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on May 17, 2021.  You asked the Plan to pay for lab tests. You say that this testing meets all of the requirements for coverage. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  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 admission is not medically necessary.  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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is medically stable and ready for discharge from the hospital. She has no complex wound care, parenteral medication, or tube feedings. She has no skilled nursing needs. While she may benefit from further therapy, the enrollee does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 7 additional home health physical therapy (PT) visits (6 were approved on appeal).  You asked the Plan to pre-approve the additional home health visits. You say that it is felt that the number of additional visits requested is medically necessary. The Plan denied your request. The Plan says the approved number of PT visits should be sufficient to meet the enrollee's needs.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health visits. Our reviewer says that the documentation does not support that the requested number of home health visits is medically reasonable and necessary. Our physician reviewer found the enrollee is a male with weakness and gait abnormality. He is receiving home PT for these and bilateral knee pain. 13 visits were initially approved. This denial is for 7 of the remaining 13 requested visits. The Physical therapy note from 12/3/2021 documents no recent hospitalizations. The current level of function documents that the patient is independent for bed mobility, stand by level of assist for transfers, and stand by level of assist to ambulate 300 feet with a single point cane. Therapy notes state patient is inconsistent with transfers, needs safety education and is limited by bilateral knee pain and decreased strength. The patient can complete a home exercise program (HEP) with assistance.  The records do not show that 7 more visits of skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The patient is standby assist for 300 feet of ambulation and standby assist for transfers. Based mobility is independent. The patient can complete a HEP with assistance. The documentation does not support the need for ongoing skilled therapy services beyond what was approved by the plan.   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 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health physical therapy (PT) visits (6 were approved on appeal).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for contact lenses provided on May 4, 2021.  You asked the Plan to pay an additional amount for contact lenses. The Plan denied your request. The Plan says the claim processed correctly based on the allowed amount for the out-of-network benefit.  Medicare generally does not cover routine 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 the contact lenses were purchased from an out-of-network provider. The Plan covers vision services when provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for contact lenses provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided on January 14, 2021.  You asked the Plan to pay for anesthesia for patient of extreme age. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this service is always bundled into payment for other services not specified.  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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that this procedure would be the best option of this patient. The Plan denied your request. The Plan says this procedure remains experimental.
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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence-based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA
indicated levels of "moderate" spinal stenosis including the planned levels of implantation at L3-4 and L4-5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of mild levoscoliosis of the lumbar spine with no documentation of the Cobb angle. There is no evidence of a bone density test showing the absence of osteoporosis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nurtec 75MG disintegrating tablet, for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says this is a self-administered drug and not covered by Medicare.  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 Nurtec 75MG disintegrating tablet, for the enrollee.   Benefits for the medication 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).