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

We decided that the Plan does not have to reimburse you for the filling (D2391) provided on December 28,
2020.
You asked the Plan to reimburse you for the dental service. You say that you should be reimbursed. The Plan
denied your request. The Plan says there is a $400 allowance every year for covered preventive and
comprehensive dental services. The Plan also says that the allowance has been exhausted.
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 and fillings could be covered, the
annual allowance has been exhausted. The record shows that the Plan paid $177 for dental services performed
on May 27, 2020, and $223 for dental services performed on December 1, 2020. Therefore, we decided that the
Plan does not have to reimburse you for the filling (D2391) provided on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on November 3, 2020.
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for inpatient mental health care are not met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services or inpatient mental health care may be covered if the patient requires active treatment. 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 inpatient mental health care.
Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found you were admitted to the acute inpatient psychiatric hospitalization on May 21, 2021 with Major Depressive Disorder. Based on the records provided, you were not showing any dangerousness to yourself or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant with treatment and having no side effects to the medication. The records do not show you required inpatient mental health treatment beyond the dates in question. There is no individualized treatment plan. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment setting beyond May 26, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 9, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. the HCPCS/CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. the HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. the HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that CPT codes 97016, 97112, and 97032 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas
device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that a therapeutic procedure for neuromuscular reeducation for sitting or standing activities was performed. There is no mention of therapy to perform these functions; the stimulation provided by the Sanexas device does not satisfy the requirements to report CPT code 97112. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care for endocarditis. From a nursing perspective, the enrollee received oral and inhaled medications and insulin. He was to complete a course of IV vancomycin daily. The enrollee had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy and speech therapy in the acute hospital. The enrollee was at a supervision assist level for functional mobility including gait to 195 feet with a rolling walker. He tolerated a regular diet and thin liquids. There are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ophthalmic exams (92134, 92235,
92250) and office visit (99204) provided on December 14, 2020.

You asked the Plan to waive the deductible for the eye exams and office visit. You say that you should only
have a $35 co-payment for these services and this provider's office came up on the Plan's provider search. The
Plan denied your request. The Plan says this provider is out-of-network. Services provided out-of-network are
subject to the $750 annual deductible before the Plan will pay their share of the cost. You had not met your
deductible at the time of service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible for physician and Medicare-covered vision services
provided out-of-network.

The item or service you asked the Plan to waive the deductible for does not fall within a benefit category where
the deductible does not apply. The provider that you saw is not within the Plan's network. It is worth noting
that the provider search result you included in your appeal also states, "some search results may include results
that are out of network." The search screen does not clearly state the network status of this provider. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for physician
and Medicare-covered vision services provided out-of-network. This cost sharing is a contractual obligation
that had not been met at the time the eye exams and office visit was received on December 14, 2020. Therefore,
we decided that the Plan does not have to waive the deductible for the ophthalmic exams (92134, 92235,
92250) and office visit (99204) provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this is a necessary annual exam. The Plan denied your request. The Plan says the enrollee previously had a Nuclear Medicine Computed Tomography (CT) scan in March 2021 that shows a lesion. The Plan recommends a full CT scan without contrast as the next step and cannot approve the requested LDCT scan.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria.
We reviewed the file and the Medicare rules. We find that the enrollee is not asymptomatic as required by Medicare rules. A lesion was found on the lung and we do not have a statement from the ordering physician that says that the enrollee is asymptomatic. We know the enrollee is a non-smoker now, but the number of years since the enrollee quit smoking is unclear. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services (97140, 97530, 97110) provided November 19, 2020 to December 31, 2020.
You asked the Plan to waive the copayment for the PT services. You say that you are requesting a full refund of the $520 you spent in copays. As a patient you believe you was not provided adequate therapy for your condition based on the diagnosis and requested therapy by the neurologist. The Plan denied your request. The Plan says the correct copayments were 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 $40 copay for physical therapy services. You have been asked to pay $520 ($40 x 13 PT visits) for the PT services. The PT services falls within the Outpatient rehabilitation 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 agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (PT) services (97140, 97530, 97110) provided November 19, 2020 to December 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Caris Molecular Intelligence (MI) testing provided on November 9, 2020.
You asked the Plan to pay for genetic testing. You say that the referring physician ordered this testing specifically for this enrollee based on multiple factors. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the Plan considers Caris MI to be experimental and investigational.
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 provider was in-network or out-of-network with the Plan. The documentation does not include prior notice 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 Caris Molecular Intelligence (MI) testing provided on November 9, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the DXA bone density study provided on August 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the DXA bone density study provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 DXA bone density study provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Medicare criteria for transfer 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 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 54 home health aide (HHA) services.
You asked the Plan to pre-approve the HHA services. You say that you are unable to care for yourself without these services. The Plan denied your request. The Plan says 6 HHA visits were approved, but the additional 54 HHA visits do not meet the Medicare definition of short-term intermittent care for HHA. The Plan also says that the HHA services are requested for long-term care to help with activities of daily living, which is considered custodial care.
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 HHA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to be receiving home health nursing services for intermittent wound care and Foley catheter care. Accompanying home health aide services are medically necessary and reasonable to assist in bathing so as to prevent catheter infection, wound infection and/or further skin breakdown. However, such care provided on a daily basis does not meet the definition of part-time or intermittent. The health plan has approved six home health aide visits. The remaining requested fifty-four home health aide visits are denied as being long-term, regular and custodial. 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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve 54 home health aide (HHA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiology office visit provided on
November 20, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you believe you had reached your
maximum out-of-pocket amount for 2020 so should not owe this amount. The Plan denied your request. The
Plan says the copayment amount 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 $50
copayment for specialist visit, up to a maximum out-of-pocket amount of $6,700. At the time this claim was
processed $4,260 of the $6,700 maximum out-of-pocket amount had been met. Therefore, your copayment
responsibility is $50.
You have been asked to pay $50 copayment for specialist visit. Specialist visits fall 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 a cardiology office visit provided on November 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Synvisc, Durolane, and Gelsyn-3 first.
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 Orthovisc. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has bilateral knee
osteoarthritis. The requested service is a new start. The enrollee has not tried and failed or had an adverse effect
from the plan's preferred step one alternatives. The medical record does not indicate a rationale why the plan's
preferred agents would not be appropriate for the enrollee. The elements of the coverage rule 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orthovisc.