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

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says members must visit a contracted provider to utilize covered benefits.
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 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 therapy to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide (G0156).You asked the Plan to pre-approve the services of home health/hospice aide. You say that you need more home health aide hours.The Plan denied your request. The Plan says these services are partially approved for 60 days until a suitable and safe alternative can be found.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services of home health/hospice aide. Our reviewer says that home health services, including home health aide services, are not shown to be medically necessary, reasonable, or coverable. Our physician reviewer found you do not currently have documented skilled nursing needs. Our reviewer also found that you do not currently have documented skilled therapy needs.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 services of home health/hospice aide have not been met.Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide (G0156).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystoscopy and treatment, basic metabolic panel, complete blood cell count, tissue exam, special stained specimen slides to examine tissue, electrocardiogram (ECG) tracing, Succinycholine chloride injection, Cefazolin sodium injection, Ondansetron hydrochloride injection, Propofol injection, Neostigmine methylslfte injection, Fentanyl citrate injection, and Ringers lactate infusion provided on January 15, 2021.
You asked the Plan to pay for the cystoscopy and treatment, laboratory services, ECG tracing, and injections. You say that you would like reimbursement for the services at the Medicare allowed rates. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the cystoscopy and treatment, basic metabolic panel, complete blood cell count, tissue exam, special stained specimen slides to examine tissue, electrocardiogram (ECG) tracing, Succinycholine chloride injection, Cefazolin sodium injection, Ondansetron hydrochloride injection, Propofol injection, Neostigmine methylslfte injection, Fentanyl citrate injection, and Ringers lactate infusion provided on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. 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 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on January 29, 2021.
You asked the Plan to waive the copayment for an office visit. You say that the services were not rendered. You also say that after waiting two hours for x-rays, you left the provider's office. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $20 copayment for an office visit. The EOC confirms that $20 is the required copayment for each office visit, including consultation, diagnosis and treatment by a specialist. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 an office visit (99214) provided on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) and a conductive
garment (E0731) provided on October 1, 2020.
You asked the Plan to pay for a neuromuscular stimulator and a conductive garment. You say that the requested
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items
are a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The Plan has documented that the items at issue are an exact
duplicate of a prior claim. Based on this information, we decided that Medicare rules for coverage of a
neuromuscular stimulator and a conductive garment have not been met. Therefore, we decided that the Plan
does not have to pay for a neuromuscular stimulator (E0745) and a conductive garment (E0731) provided on
October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination coded 74230 provided on February 22, 2021.You asked the Plan to pay for the radiologic examination. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not payable as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 74230 is radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neckradiograph(s) and delayed image(s), when performed, contrast (eg, barium) study.
We find that CPT code 74230 is not supported in the medical record. Specifically, these services were billed with place of service 22 (outpatient). The documentation shows that the enrollee was inpatient during this date of service. This means this code was billed with an incorrect place of service. Based on this information, we decided that Medicare rules for coverage of the radiologic examination have not been met.Therefore, we decided that the Plan does not have to pay for the radiologic examination coded 74230 provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and laboratory test provided on December 22, 2020 and December 31, 2020.You asked the Plan to waive the deductible for the office visit and laboratory test. You say that your previous physician retired forcing you to change physicians. You say that the doctor was out-of-network until 2021 but they should be paid in-network.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear,accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit and laboratory test were received on December 22, 2020 to December 31, 2020.Therefore, we decided that the Plan does not have to waive the deductible for the office visit and laboratory test provided on December 22, 2020 and December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient coded G0463 provided from October 31, 2020 to November 1, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit for assessment and management of a patient. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0463 is hospital outpatient clinic visit for assessment and management of a patient.
We find that CPT code G0463 is not supported in the medical record. Specifically, this code was billed without an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the hospital outpatient clinic visit for assessment and management of a patient have not been met. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient coded G0463 provided from October 31, 2020 to November 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation -problem focused (D0140) provided March 22, 2021.You asked the Plan to pay for the limited oral exam. You say that the provider is listed in the provider directory and you would like the service covered. The Plan denied your request. The Plan says the claims from this provider have been reprocessed as in-network however the limited oral evaluation is not a covered service.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 limited oral evaluation -problem focused (D0140) provided March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) ST visits.You asked the Plan to pre-approve an additional ten (10) ST visits. The Plan denied your request. The Plan says an additional ten (10)speech therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 an additional ten (10) ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that in this case, your cognitive impairment prevents you from being able to cooperate with skilled speech therapy. Furthermore, you are able to swallow an oral diet without complications.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) ST visits have not been met.Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) ST visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of root canal obstruction and biologic materials to aid in soft and osseous tissue regeneration
You asked the Plan to pre-approve treatment of root canal obstruction (D3331) and biologic materials to aid in soft and osseous tissue regeneration (D3431). You say that you need these services. The Plan denied your request. The Plan says these services are not covered under your dental benefit package.
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 treatment of root canal obstruction and biologic materials to aid in soft and osseous tissue regeneration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture and mandibular partial denture.
You asked the Plan to pre-approve maxillary partial denture and mandibular partial denture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items exceed your benefit limit.
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 dentures once every five years. We looked at the file and Medicare rules. Review of the file shows that you previously received dentures on March 4, 2021. Five years since you previously received dentures has not passed. Based on this information, we decided that the Plan's rules for coverage of maxillary partial denture and mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture and mandibular partial denture.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Prolia.

You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says a tier exception is not permitted.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. The drug falls within the Medicare Part B prescription drugs benefit category. This means that this is 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 pre-approve a tier exception for Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient SNF services.
You asked the Plan to pre-approve the inpatient SNF services. You say that the enrollee's family says the enrollee is not at their normal level of functioning. The Plan denied your request. The Plan says the enrollee does not meet Centers for Medicare & Medicaid Services (CMS) criteria for this level of medical care, and treatment for her condition can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient SNF services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the inpatient SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spinal canal and contents without contrast materials (72141).You asked the Plan to pre-approve MRI of spinal canal and contents. You say that you need this service.The Plan denied your request. The Plan says the requested service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI of spinal canal and contents. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that in this case, the enrollee had a motor vehicle crash in 2018. The records indicate he had a C-spine injury at that time. The enrollee had primarily low back complaints. The requested test was ordered by the primary care physician. No medical records from that physician are available. He was then seen by an orthopedic surgeon who did not feel that the MRI was necessary at that time prior to completion of physical therapy and a Medrol dose pack. The medical records do not support the medical necessity and reasonableness of the requested service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of spinal canal and contents have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spinal canal and contents without contrast materials (72141).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 4, 2021.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.

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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar interspinous decompression device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction
device, without fusion, including image guidance when performed, with open decompression, lumbar; single
level (22867). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The
Plan says there are not enough studies to show that use of this device is better than regular spine surgery.
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 insertion of interlaminar/interspinous
process stabilization/distraction device, without fusion, including image guidance when performed, with open
decompression, lumbar; single level (22867). Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found the device remains
experimental. More research is needed to show safety and efficacy of the interlaminar device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device,
without fusion, including image guidance when performed, with open decompression, lumbar; single level
(22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar
interspinous decompression device.