Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for ear wax removal (69210). We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation (99397), a pneumococcal vaccine (90732), and vaccine administration (90471).

You asked the Plan to pay for ear wax removal (69210). You say that these are all Medicare covered services. The Plan says that these services were not billed correctly.

We decided that the Plan has to pay for ear wax removal (69210).

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 states that this code was denied because it was submitted with an inappropriate bilateral modifier. However, no documentation such as a claim form has been submitted showing this code was billed with a modifier, and the modifier is not shown on the submitted explanation of benefits. Therefore, we decided that the Plan has to pay for ear wax removal (69210).

We also decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation (99397), a pneumococcal vaccine (90732), and vaccine administration (90471).

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that a status code of N indicates Non-covered service. 

In this case, the CPT Code Manual definition of code 90732 is pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use. While code 90471 is used to report immunization administration it is specifically for OPPS hospitals billing for the hepatitis B vaccine administration. These codes represent conflicting services. 

The periodic comprehensive preventive medicine reevaluation at issue was reported with code 99397, which has a status code of N, indicating that it is a non-covered service. Of note, there is a more appropriate code to report a Welcome to Medicare preventative visit. Therefore, we decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation (99397), a pneumococcal vaccine (90732), and vaccine administration (90471).

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 pay for physical therapy provided on December 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the rendering physician is out-of-network. The Plan says that prior authorization was not obtained.

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 physical therapy provided on December 19, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for pharmacogenomic testing provided on January 11, 2021.

You asked the Plan to pay for pharmacogenomic testing. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct,
because this testing does not meet the Medicare criteria for coverage.

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 outof-
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 for this
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for
pharmacogenomic testing provided on January 11, 2021.

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: 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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for elective hip replacement surgery. The enrollee's medical conditions are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 20, 30, and 31.

You asked the Plan to pre-approve the dental services. You say that you are missing several teeth due to periodontal disease. You say that you prefer implants to replace your teeth. You also say that implants would allow you to chew better. The Plan denied your request. The Plan says implants are covered when 1 tooth per arch is missing. The Plan says that there is more than 1 tooth missing per arch. The Plan also says that the requested implants are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, implants are not covered when you are missing more than 1 tooth in each arch. Based on the requested implants, you are missing 8 top teeth and 5 bottom teeth. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth # 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 20, 30, and 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the motorized scooter (Hoveround) (CPT code E1399), for the enrollee.

You asked the Plan to pay for the motorized scooter. You say that the enrollee is capable of using a motorized scooter. The Plan denied your request. The Plan says this upheld decision is purely based on the incorrect CPT/HCPCS code being submitted when there is a more appropriate code available for the services requested.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Based on this information, we decided that Medicare rules for coverage of the motorized scooter have not been met. The provider is requesting coverage for an unlisted code when there is a more appropriate code for this service. A review of CMS guidelines states an unlisted code cannot be covered if there is an appropriate code for the requested service. Unlisted codes should be reported only if no other specific codes adequately describe the procedure or service. The health plan will approve the appropriate HCPCS code (K0813-K0899), if requested. Therefore, we decided that the Plan does not have to pay for the motorized scooter (Hoveround) (CPT code E1399), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702) for the enrollee.

You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 the device. Our physician reviewer found the record indicates that the enrollee suffered a stroke in 2014 that resulted in left hemiparesis with spasticity. The provided medical records are insufficient to demonstrate the medical reasonableness and necessity of the requested service as defined by Medicare rules. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your care needs can be met in the skilled nursing facility setting or at home.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and congestive heart failure after recent coronary artery bypass grafting. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for extracapsular cataract removal provided from August 12, 2020, to August 26, 2020.

You asked the Plan to waive the copayments for extracapsular cataract removal. You say that you were told that the services would be 100% covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You received extracapsular cataract removal on August 20, 2020, at an outpatient hospital facility. Extracapsular cataract removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. 

You received extracapsular cataract removal on August 26, 2020, at an outpatient hospital facility. Extracapsular cataract removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. 

The total amount you owe is: $590. 

You have been asked to pay the total copayment amount of $590 for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for extracapsular cataract removal provided from August 12, 2020, to August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the records received do not indicate that the member needs an intensive therapy program with multiple visits from a rehab doctor per week.

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 there are no complex nursing or rehabilitation needs. There is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office consultation 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 that there are in-network providers available to render the requested service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. However, the requested service is not available with an in-network provider. The Plan indicated that you felt compelled to switch to another medical group in order to access this service; however, this is not relevant to the issue in this case. The Plan has failed to arrange for specialty care out of the medical group due to a lack of accessibility within the group. Therefore, we decided that the Plan has to pre-approve an office consultation to be rendered by the out of network (OON) provider.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that your doctor prescribed water pills causing to need approximately one package of supplies per week. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on December 24, 2020 by an out of network provider.

You asked the Plan to pay for the physical therapy treatments. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 physical therapy provided on December 24, 2020 by an out of network provider.