Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 30, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, 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 psychotherapy 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 psychotherapy services provided on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prosthetics.
You asked the Plan to pre-approve Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973) and addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988). You say that the enrollee's current socket is very loose, and the prosthetic foot currently does not have plantar flexion. The Plan denied your request. The Plan says the requested replacement K3 foot exceeds the enrollee's needs and cannot be covered. Current foot still under warranty.
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 Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973) and addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the patient's current foot is not functional or in disrepair. Additionally, the documentation reveals the patient uses a 2 WW for ambulation which does not support the enrollee is a K3 ambulator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973) and addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988) have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity prosthetics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap from the trunk described by code 15734 provided on October 14, 2020.
You asked the Plan to pay for code 15734. You say that the medical records support the billing of CPT code 15734. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 15734.
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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk. 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 code 15734. Our reviewer says that the medical records do not support the billing of CPT code 15734. Our physician reviewer found in this case, the operative note does not indicate that either the external oblique or the transversus abdominis was released from their lateral attachments. The elements of CPT code 15734 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 code 15734 have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap from the trunk described by code 15734 provided on October 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the lumbar and thoracic spine (72148, 72146) provided October 24, 2020.
You asked the Plan to waive the copayment for the MRI's. You say that only one copayment should be applied. The Plan denied your request. The Plan says a copayment is applied for each MRI procedure. The correct copayment was applied.
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 $100 copayment for Each MRI at a freestanding facility. You have been asked to pay a $100 copayment for each MRI (for a total of $200). 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 Magnetic Resonance Imaging (MRI) of the lumbar and thoracic spine (72148, 72146) provided October 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you need a LTACH admission. The Plan denied your request. The Plan says it is not medically necessary for you to be in a LTACH.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. At the time of the request, the member's status is stable and improving. Based on the most recent progress note from April 21, 2021, the acute conditions present on admission are stable. The member is stable on trach collar with need for frequent suctioning. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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 health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell therapy, vasopneumatic device therapy, and subcutaneous injection of a Nutri-Pharmaceutical blend (97016, 97032, J3490, 97112) provided October 13, 2020.
You asked the Plan to pay for the electrical cell therapy, vasopneumatic device therapy, and subcutaneous injection of a Nutri-Pharmaceutical blend. You say that the services were medically necessary. The Plan denied your request. The Plan says these treatments are investigational and not covered.
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 pay for the electrical cell therapy, vasopneumatic device therapy, and subcutaneous injection of a Nutri-Pharmaceutical blend. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records did not show the patient having completed a full trial of physical therapy and other conservative measures prior to considering this second-line treatment option. Also, this therapy does not have sufficient supportive evidence of general safety and effectiveness for sciatica and chronic pain over more standard therapies. 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 electrical cell therapy, vasopneumatic device therapy, and subcutaneous injection of a Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for electrical cell therapy, vasopneumatic device therapy, and subcutaneous injection of a Nutri-Pharmaceutical blend (97016, 97032, J3490, 97112) provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual gym membership for 2020 purchased December 27, 2019.

You asked the Plan to pay for the annual gym membership for 2020 purchased December 27, 2019. You say that you paid for your 2020 gym membership in 2019. The Plan denied your request. The Plan says The date of service for this benefit is the date you make payment. For example, if you pay on December 15 for a gym membership that starts January 1, December 15 is the date of service.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers annual gym membership fees only when the date of service is in the same calendar year as the benefit being purchased.

The Plan's rules for coverage of gym benefits have not been met because Your purchase was made in 2019. The Plan contract clearly states that the date of service will be applied to the year in which the purchase was made. Therefore, we decided that the Plan does not have to pay for the annual gym membership for 2020 purchased December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on September 5, 2020, through September 10, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the correct code was reported and is supported medically. The Plan denied your request. The Plan says that an itemized bill is required to process this claim.
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 indicated why an itemized bill would be necessary for these services. It is the burden of the Health Plan to substantiate their denial with evidence. Therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on September 5, 2020, through September 10, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2751) provided on December 10, 2020.
You asked the Plan to pay for the crown. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is 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. 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 crown (D2751) provided on December 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography provided on August 31, 2020.

You asked the Plan to waive the copayment for the CT angiography, chest. You say that there was no other place to get the CT scan at the moment. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for Outpatient Diagnostic Tests at an outpatient hospital setting.

You have been asked to pay a $200 copayment for the computed tomographic (CT) angiography, chest (71275). The CT falls within the Outpatient Diagnostic Tests at an outpatient hospital setting 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 the computed tomographic angiography provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided September 8, 2020.

You asked the Plan to pay forthe knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee.The Plan denied your request. The Plan says the member states he did not have a video or telephonic telehealth visit with the ordering physician so the claim should be denied.

The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment supplier is allowed to contact enrollees without permission.

We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met.Therefore, we decided that the Plan doesnot have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided September 8, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Rituxan (rituximab).
You asked the Plan to pre-approve Rituxan. You say that your physician prescribed this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of one of Truxima, Rituxan Hycela, or Ruxience before it will approve Rituxan.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Rituxan. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Rituxan. Our physician reviewer found you have not tried and failed the Plan's preferred drugs of at least one of Truxima, Rituxan Hycela, or Ruxience. The documentation does not show that these drugs would likely be less effective and/or have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Rituxan (rituximab).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Golden PR-510 lift chair provided on September 16, 2020.
You asked the Plan to pay for a lift chair. You say that the requested item is medically necessary equipment to assist you with daily living. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a Golden PR-510 lift chair provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services provided on December 9, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that please overturn the denial and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the outpatient surgical services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an intravascular ultrasound (37253) provided September 10, 2020.
You asked the Plan to pay for the intravascular ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel. We find that CPT code 37253 is not supported in the medical record. Specifically, the operative report is not detailed enough to determine if this service was rendered as billed. Based on this information, we decided that Medicare rules for coverage of the intravascular ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an intravascular ultrasound (37253) provided September 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Aide (HHA) services.
You asked the Plan to pre-approve HHA services. You say that you need home health services. The Plan denied your request. The Plan says you do not need skilled nursing or therapy.
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 HHA services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested services are for custodial care without a skilled need. The requested home health services are 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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Aide (HHA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99214) provided November 24, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 Urgent Care. You have been asked to pay a $40 copayment for the urgent care visit. the urgent care visit falls within the Urgent Care 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 urgent care visit (99214) provided November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing (86769-CS) provided on October 27, 2020.

You asked the Plan to pay for COVID-19 testing. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 86769-CS is not supported in the medical record. Specifically, code 86769 is not listed as a code that is appropriate for the CS modifier. Based on this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 testing (86769-CS) provided on October 27, 2020.