Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 13, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the enrollee should not be held responsible for this. The Plan denied your request. The Plan says the enrollee's benefit maximum has been met.
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, comprehensive oral evaluation is limited to one every 36 months. The record shows that the enrollee last received a comprehensive oral evaluation on July 5, 2019 and the enrollee's comprehensive oral evaluation benefit has been exhausted. The record also shows that you were appropriately advised of the enrollee's benefits when you contacted the Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87798, 87481, 87640, 87653) provided on January 22, 2021.
You asked the Plan to pay for laboratory services. You say that you can not afford these charges. The Plan denied your request. The Plan says this claim must be submitted to your primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you
and the provider to submit the bill to your primary insurance. As the secondary insurer, the Plan cannot be held responsible for laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for laboratory services (87798, 87481, 87640, 87653) provided on January 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy and needle insertion provided on May 13, 2020.
You asked the Plan to waive the copayment for physical therapy and needle insertion. You say that you should be charged one copayment per visit. 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 $35 copayment per visit, per therapy type, for outpatient rehabilitation services. Your contract with the Plan also clearly says you must pay a $35 copayment for physician/practitioner services, including doctor's office visits.
The records show that you had physical therapy services with a copayment of $35 and needle insertion(s) with a specialist/practitioner, with a copayment of $35, which total $70 for the services received. Physical therapy falls within the outpatient rehabilitation services and needle insertion 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 physical therapy (97110, 97140) and needle insertion (20561) provided on May 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ambulance services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee must receive care from a network provider.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ambulance services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the criteria for coverage of IRF care have been met.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needed care can be provided safely in a less intensive setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture and non-surgical management of a humerus fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74176).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the CT scan of the abdomen and pelvis was requested due to suspected kidney stone. The patient had not had an ultrasound which is standard for screening. Also, no urinary testing was ordered. A CT scan is not indicated until first line testing is completed.
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74176).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Venofer for the enrollee.
You asked the Plan to pre-approve Venofer. You say that Venofer is medically necessary for the enrollee. The
Plan denied your request. The Plan says that Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Venofer. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found
enrollee is iron deficient and has inflammatory bowel disease. We looked at this physician's review, the file,
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Venofer have
been met. Therefore, we decided that the Plan has to pre-approve Venofer for the enrollee.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy.
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of authorization for the requesting physical therapy is
correct, because there is no documented failure of a home exercise program or indication that the enrollee's
residual deficits could not be addressed by a home exercise program.
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 physical therapy. 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 the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy and the records do not demonstrate a significant change or deficit that requires the unique skills of a professional therapist to safely and effectively provide treatment. There is no evidence that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-Syn injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the information provided does not show that the policy requirements have been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have knee pain in the setting of a partial meniscal tear and degenerative changes. Prior treatment was over-the-counter. Response to a recently prescribed anti-inflammatory is not documented. The provision of steroid injections, rehabilitative therapy and/or home exercise is not documented. Viscosupplementation is appropriate for patients with osteoarthritis who have failed conservative therapy. The enrollee does not yet meet the criteria. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-Syn injection for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for outpatient mental health therapy with a licensed professional counselor (LPC).
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says a licensed professional counselor is not recognized as a qualified Medicare provider.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. A licensed professional counselor is not eligible to bill Medicare. The Plan did not pre-approve the referral. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for outpatient mental health therapy with a licensed professional counselor (LPC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5298) received January 28, 2021 from a non-participating provider.
You asked the Plan to pay for the hearing aid. You say that the hearing aids are necessary. The Plan denied your request. The Plan says hearing aids purchased outside of the Plan's hearing vendor network will not be covered.
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 Plan-participating vendor. We looked at the file, and the Plan's rules. You purchased the hearing aid from outside of the Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5298) received January 28, 2021 from a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 7, 2021.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says that the Plan won't pay for excluded medical services.
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 through the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid 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 reimburse you for hearing aids provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on June 29, 2020 and July 20, 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 claim was processed correctly.
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 out-of-network supplemental dental benefits at a 50% coinsurance. We looked at the file and the Plan's rules. The file shows that you received dental services from an out-of-network provider. The provider agreed to write off the exam charges. The Plan has asked you to pay a 50% coinsurance for the remaining services, per your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the dental services rendered on June 29, 2020 and July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), amalgam (D2140), crown (D2750), and re-cement or re-bond crown (D2920) provided from June 12, 2020, to October 27, 2020 by an OON provider.
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, amalgam, crown, and re-cement or re-bond crown. You say that 50% of these services should have been covered by the Plan. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived. 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 a 50% coinsurance for the crown and re-cement or re-bond crown, and you are also responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), amalgam (D2140), crown (D2750), and re-cement or re-bond crown (D2920) provided from June 12, 2020, to October 27, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe chiropractic services provided from January 8, 2021, to January 19, 2021.You asked the Plan to waive the copay forthe services provided. You say that you were advised you could be reimbursed for the copays.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copay for each Medicare-covered chiropractic visit. The file shows that you received manual manipulation of the spine to correct subluxation. This is a Medicare-covered chiropractic service. You have been asked to pay a $20 copay for each Medicare-covered chiropractic visit. The service falls within the chiropractic 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 agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay forthe chiropractic services provided from January 8, 2021, to January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 21, 2020.
You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services was performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The documentation does not support that an additional twenty-five (25) days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services.