Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have been limping since your hip replacement. 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 pre-approve foot orthotics.
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 care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for a heart attack and coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, 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: 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 care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for hypertensive urgency, transient ischemic attack and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the podiatry services provided on February 3, 2021.
You asked the Plan to waive the cost share for the services provided. You say that the initial visit to the podiatrist was charged as a specialist visit. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.
The services fall within the podiatry services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on February 3, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the podiatry services provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites and sales tax provided on January 6, 2021 by an OON provider.

You asked the Plan to pay for the resin-based composites and sales tax. You say that you feel you should have 50% coverage for these services. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that tax is not paid when the provided services are not paid.

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, you are responsible for 100% of the cost for dental services rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the two resin-based composites and sales tax provided on January 6, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on June 30, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, this claim was billed with with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on June 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided August 28, 2020.
You asked the Plan to pay for the air ambulance services. You say that the services provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for air ambulance services were not met.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the air ambulance services. Our reviewer says that the air ambulance services were not medically reasonable and necessary. Our physician reviewer found that the enrollee presented with acute on chronic renal failure. The enrollee was known to be anemic and was stool heme positive. The medical record does not support the presence of an acute gastrointestinal bleed. The enrollee had renal failure that required the initiation of dialysis. The record does not indicate an indication for emergent dialysis. The record does not support that the enrollee's condition required immediate and rapid transportation that could not have been provided by ground ambulance. The elements of the coverage rule are not satisfied. 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740), core buildup (D2950) and periodontal scaling (D4341).
You asked the Plan to pre-approve the porcelain/ceramic crown, core buildup, and periodontal scaling. You say that these services are medically necessary for your pain. The Plan denied your request. The Plan says these are not covered services under your supplemental benefit.
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 the porcelain/ceramic crown (D2740), core buildup (D2950) and periodontal scaling (D4341).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services. This enrollee does require skilled therapy services; however, skilled services are not needed on a daily basis. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive (92014) provided February 3, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you were told there would be no charge for the visit and do not feel it is fair to now be charged a copayment. The Plan denied your request. The Plan says due to a history of cataracts your eye exam is considered a Medicare-covered eye exam to diagnose and treat diseases of the eyes and the copayment was assessed correctly.
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. We looked at the file and the Plan's rules. 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 for a Medicare-covered eye exam to diagnose and treat diseases of the eyes. Based on this information, we decided that the Plan's rules for coverage of the medical eye exam have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive (92014) provided February 3, 2021.
Your complaint about potentially being provided misinformation about the cost of your services from your provider's office or a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical, occupational and speech therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical, occupational and speech therapy to be provided by the requested out-of-network provider. You say that the Plan has not been able to provide coverage for therapy with providers that are knowledgeable about Amyotrophic Lateral Sclerosis (ALS). The Plan denied your request. The Plan says generally the member must receive care from a network provider. In most cases, care the member receives from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The member's Evidence of Coverage states care will be directed outside of the primary network only if it has been determined that they cannot provide the necessary care to the member.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical, occupational and speech therapy to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (99203, 99213) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve this service. 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 this service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. Evaluation and testing to determine the need for the Inspire device can be done by network providers. The Plan has noted that after this evaluation, if you meet criteria for this treatment, a referral to a provider who can perform this surgery can be requested. Therefore, we decided that the Plan does not have to pre-approve a consultation (99203, 99213) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) provided November 3, 2020.
You asked the Plan to pay for the additional periapical x-rays. You say that you were misled about the services provided and disagree with the cost. The Plan denied your request. The Plan says one periapical x-ray was covered on the same date of service and therefore, the additional x-rays are not covered.
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. The Plan covers one periapical x-ray per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that one periapical x-ray was covered on November 3, 2020. Based on this information, we decided that the Plan's rules for coverage of the additional periapical x-rays have not been met. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) provided November 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh provided on February 12, 2021.

You asked the Plan to pay for the PET with CT. You say that the service was medically necessary. The Plan denied your request. The Plan says this procedure was not reported with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and diagnosis code.

We find that diagnosis code R59.0 is not listed as a diagnosis code for Pet for Solid Tumors. Based on this information, we decided that Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses (V2784) received on December 2,
2020.

You asked the Plan to pay for polycarbonate lenses. You say that you were not aware you were receiving this
item, or that it would not be covered. The Plan denied your request. The Plan says The Plan says the benefits
were applied correctly. The benefit maximum allowance had already been met.

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 up to a $100 allowance, then you are responsible for paying the
difference.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of polycarbonate lenses have not been met. Specifically, the record shows that you had exhausted
your eyewear benefit maximum of $100 and are therefore, responsible for payment of this service. Therefore,
we decided that the Plan does not have to pay for polycarbonate lenses (V2784) received on December 2, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the lumbar ESI. We decided that the Plan does not have to pre-approve MAC.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.
We decided that the Plan has to pre-approve the lumbar ESI.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. The rules say that a lumbar ESI is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the ESI is medically necessary and the MAC is not medically necessary. Our physician reviewer found the enrollee has lumbar radiculopathy. She had an ESI that produced greater than six months of pain relief. She is doing a home exercise program and using Percocet and over-the-counter analgesics. She is also doing moist heat and stretches. The lumbar ESI meets the criteria for coverage and is medically necessary. The separate charge for fluoroscopy is not allowed, as it is an integral part of the procedure. MAC is not recommended when performing the ESI and is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ESI are met. Therefore, we decided that the Plan has to pre-approve the lumbar ESI.
We also decided that the Plan does not have to pre-approve MAC.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the ESI is medically necessary and the MAC is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MAC are not met. Therefore, we decided that the Plan does not have to pre-approve MAC.
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.