Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic services and injections provided on November 10, 2020.  You asked the Plan to pay for therapeutic services and drugs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services have been misrepresented and are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of, a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under state law. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug not otherwise classified code.  We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.  Based on this information, we decided that Medicare rules for coverage of therapeutic services and drugs have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic services and injections provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for genetic testing (81206) provided on July 14, 2021.  You asked the Plan to waive the coinsurance for the genetic testing. You say that the services should be covered as the bill is inconsistent and you need this service every three months. The Plan denied your request. The Plan says the coinsurance 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 Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a 20% coinsurance for genetic testing (the allowed amount is $679.94 x 20% = $135.99). Genetic testing falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing (81206) provided on July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee is not at his prior level of care. The Plan denied your request. The Plan says there is no need for daily skilled therapy or nursing 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 SNF services. Our physician reviewer found that the enrollee does not require the skilled nursing services of a skilled professional nurse to provide treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. He is standby assist for ambulation of 200 feet with a four-wheeled walker. His high functional level does not require skilled therapy services with  a qualified therapist to provide treatment in a SNF. The enrollee does not require skilled services on a daily 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 8, 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 the services were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hospital services provided on October 26, 2019.

You asked the Plan to reimburse you for the hospital services. You say that two years ago when you were outside the United States you fell at the mountain, and you were taken to the hospital emergency department by ambulance, and you received treatment for about two hours with an x-ray and stitches for the injured area.

You say this treatment was due to an accident and the receipt you submitted shows emergency room treatment was provided, which the Plan covers around the world. The Plan denied your request. The Plan says there are no medical records or physician notes for the Plan to determine if this was an urgent/emergent visit.

The Plan contract says that you must submit to the Plan a discharge summary or equivalent medical documentation and proof of payment in English and U.S. dollars for reimbursement. The Plan will review the documentation for medical necessity and appropriateness before reimbursement is made.

We looked at the file and the Plan's rules. The file shows that there are no medical records or physician notes for the Plan to determine if this was an urgent/emergent visit. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to reimburse you for hospital services provided on October 26, 2019.
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. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the operative tissue ablation and reconstruction of atria (33259) provided on June 25, 2021.  You asked the Plan to pay for the operative tissue ablation and reconstruction of atria (33259). You say that the medical records that support the denied procedure should be reviewed. The Plan denied your request. The Plan says CPT code 33259 is not supported in the documentation therefore is 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 33259 is operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure).  We asked our coder 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 the operative tissue ablation and reconstruction of atria (33259). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation of tissue ablation and reconstruction of atria. The operative report also does not describe lesions or pattern of scar tissue (the maze), and therefore, this procedure cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the operative tissue ablation and reconstruction of atria (33259) have not been met. Therefore, we decided that the Plan does not have to pay for the operative tissue ablation and reconstruction of atria (33259) provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right total knee joint replacement at the hospital under inpatient status.

You asked the Plan to pre-approve a right total knee joint replacement at the hospital under inpatient status. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 right total knee joint replacement at the hospital under inpatient status. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or current medical history that would place you at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right total knee joint replacement at the hospital under inpatient status 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 a right total knee joint replacement at the hospital under inpatient status have not been met. Therefore, we decided that the Plan does not have to pre-approve a right total knee joint replacement at the hospital under inpatient status.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a stair lift purchased on May 6, 2021.  You asked the Plan to pay for the lift. You say that you live alone in a three-story home. The Plan denied your request. The Plan says this is a convenience item  and not primarily medical in nature.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift 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 pay for a stair lift purchased on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urinary intermittent catheter with insertion supplies (A4353) provided July 10, 2021.  You asked the Plan to waive the copayment for the urinary supplies. You say that you had called customer service and was told that this would be 100 percent covered. The Plan denied your request. The Plan says the claim was processed with the correct coinsurance applied per the Evidence of Coverage  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare covered items.    You have been asked to pay $83.10 ($415.50 x 20%) for the urinary supplies. The urinary supplies fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urinary intermittent catheter with insertion supplies (A4353) provided  July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided October 6, 2021.  You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you were unaware that the provider was out-of-network. 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 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on August 4, 2021.  You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids are only covered when purchased from a participating provider.  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 purchased from a participating provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a participating provider. 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 hearing aids provided on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the proparacaine 0.5% (A9270) provided on July 1, 2021.  You asked the Plan to pay for the self-administered drug. You say that you have no idea what the $47.40 charge for self-administered drug is for. You say that you did not take any drugs when you were in the emergency room. You say that they administered the only drugs that you did have. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.  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 pay for the proparacaine 0.5% (A9270) provided on July 1, 2021.   Benefits for the self-administered drug 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.

You asked the Plan to pre-approve Entyvio. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Entyvio. Our reviewer says that the services are not medically necessary. Our physician reviewer found 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. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve a lumbar epidural steroid injection.  You asked the Plan to pre-approve the requested services. You say that the enrollee received 50% relief. The Plan denied your request. The Plan says that there have not been 3 months since the first injection.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She takes Tramadol for the pain. She has tried physical therapy and is doing a home exercise program. She achieved 50% pain improvement for 3 months from the previous injection. The request is for another epidural steroid injection.  The request meets all of the coverage criteria.  Therefore, the procedure is medically reasonable and 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve a lumbar epidural steroid injection.  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 pre-approve the assistant surgeon services rendered on August 31, 2021.  

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 provider type is not covered.  

The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).  

We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pre-approve the assistant surgeon services rendered on August 31, 2021.