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

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve pain management services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 pain management services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve the insertion of an interspinous stabilization device. You say that this is medically necessary. The Plan denied your request. The Plan says this is an experimental procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of an interspinous stabilization device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacer devices remain experimental for the treatment of spinal stenosis. More research is needed to show safety and efficacy of the 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 the insertion of an interspinous stabilization device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Standing feature (E2301) for a power wheelchair.
You asked the Plan to pre-approve the Power Standing feature. You say that the standing feature is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that a power standing feature (E2301) is non-covered as it is not primarily medical in nature. We looked at the file and Medicare rules. The requested item is not covered under Medicare. Based on this information, we decided that Medicare rules for coverage of the Power Standing feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a Power Standing feature (E2301) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth # 29.
You asked the Plan to pre-approve the dental services. You say that you are very sick and have cancer. You say that it is affecting your jaw and mouth. You say that you need the services to be covered. You say that you want your teeth fixed. You also say that the services are urgent. The Plan denied your request. The Plan says 2 crowns are covered per calendar year. The Plan says that the frequency limit for this service has been reached. The Plan also says that core build up is not listed as 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 frequency limit of 2 crowns per calendar year has been reached. The record shows that the Plan paid for crowns that you received on August 21, 2020, and October 16, 2020. Additionally, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth # 29.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (74018) provided on May 27, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you should not be charged because this x-ray was interpreted incorrectly. The Plan denied your request. The Plan says this 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 $50 copayment for diagnostic procedures and tests. You have been asked to pay a $28.67 copayment for an x-ray because the allowed amount for this service is less than $50. 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 x-ray (74018) provided on May 27, 2020.
Your complaint about this x-ray not being read correctly 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound, breast, unilateral, real time with image documentation (76642).

You asked the Plan to waive the copayment for the breast ultrasound. You say that you went for a mammogram because your doctor ordered it. He did not order an ultrasound and you would have never had it done had you know you were going to have to pay this large copay. You are on a very limited income. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was 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 $100 copayment for each covered radiological diagnostic service, not including x-rays.

You have been asked to pay $86.30 copayment for the breast ultrasound. The copayment is $100 but the allowable was $86.30, therefore you are responsible for $86.30. The breast ultrasound 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 copayment for ultrasound, breast, unilateral, real time with image documentation (76642).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency services rendered on June 19, 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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was billed with an inappropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency services rendered on June 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (71045) provided on September 28, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that the documentation supports one unit of CPT code 71045 which was previously processed and paid.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded evidence that one unit of CPT code 71045 has been paid. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided on September 28, 2020.
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: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne CDx testing.

You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was determined to be medically reasonable and necessary for the management of the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee does not meet the criteria for this testing.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for FoundationOne CDx testing.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit provided on December 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a rest home visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained by a participating 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a rest home visit provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation, per site (D7953) 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 you must receive your care from an in-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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation, per site (D7953) to be rendered by the out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy (PT) services.

You asked the Plan to pre-approve the additional home PT services. You say that more PT is necessary at this time to assist with function. The Plan denied your request. The Plan says you have received 22 home PT visits and have progressed to the point where the skills of a therapist are no longer necessary to maintain your condition.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home PT services. Our reviewer says that the documentation does not support the medical necessity of continued home health PT services. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration beyond the 22 visits already approved. She is walking 175 feet with a rolling walker with contact guard assistance and is stand-by assist for transfers. Further utilization of the home exercise program appears appropriate based on the patient's status after completion of the 22 approved therapy sessions.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional home PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health physical therapy (PT) services.
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 this is designed to provide extra support and fit your body. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation oncology consult provided by an out of network (OON) provider.
You asked the Plan to pay for the radiation oncology consult. You say that this is a continuity of care issue and would like to see a provider that offers proton therapy. The Plan denied your request. The Plan says services can be safely transitioned to an in-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider at issue in this case is not a network provider with the Plan. 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 radiation oncology consult. Our reviewer says that the service is not medically necessary. Our physician reviewer found that an in-network urologist or oncologist would be able to provide necessary care. Our doctor found that it is safe to transition you to an in-network provider and that is not medically necessary for you to continue treatment with the out-of-network provider 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 radiation oncology consult have not been met. 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 pay for the radiation oncology consult. Therefore, we decided that the Plan does not have to pay for the radiation oncology consult provided by an out of network (OON) provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). Medicare coverage criteria are not met.

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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision, excessive skin and subcutaneous tissue
(includes lipectomy) (15836).

You asked the Plan to pre-approve the surgical procedure. You say that a panniculectomy is the only
alternative and is a medical necessity. The enrollee is not interested in abdominoplasty nor is she concerned
with the postoperative appearance. This surgery is necessary for your patient to have the best quality of life.
The Plan denied your request. The Plan says this request is not medically necessary because the records show
the enrollee does not have a malformed body part and this surgery is cosmetic in nature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve
the excision, excessive skin and subcutaneous tissue (includes lipectomy) (15836).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral Arthrodesis.

You asked the Plan to pre-approve bilateral Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). You say that you need this procedure for pain relief. The Plan denied your request. The Plan says there is no documentation of a least 75% reduction of pain after sacroiliac joint injection.

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 bilateral Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an MRI does not show sacroiliitis. The request is deemed 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 bilateral Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279) have not been met. The requested provider is not in-network. Therefore, we decided that the Plan does not have to pre-approve bilateral Arthrodesis.