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

We decided that the Plan does not have to pay for the assessment for prescription eye wear using a range of
lens powers (eye refraction) (92015) and the outpatient visit (99204) received January 12, 2021.
You asked the Plan to pay for the eye refraction and outpatient office visit. You say that you should not be
charged for this service. The Plan denied your request. The Plan says eye refractions are not covered by the
Plan.
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 $45
copayment for specialist office visit. The Plan must follow Medicare rules. The rules say that Medicare does
not cover routine vision services and eyewear.
The eye refraction is considered routine vision services or eyewear. Original Medicare does not cover routine
eye exams (eye refractions) for eyeglasses/contacts. You have been asked to pay a $45 copayment for the
office visit. This means that you have been asked to pay the correct amount based on your contract with the
Plan. Therefore, we decided that the Plan does not have to pay for the assessment for prescription eye wear
using a range of lens powers (eye refraction) (92015) or provide additional payment for the outpatient visit
(99204) received January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the wellness visit. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.
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 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 wellness visit provided on January 20, 2021 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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke and an above the knee
amputation because of peripheral vascular disease and gangrene. Medical problems are stable. There are no
complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right shoulder surgery (23430, 29828).

You asked the Plan to pre-approve right shoulder surgery. You say that this request is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested surgery is not medically reasonable and necessary at this time.

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 right shoulder surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 74-year-old male was being treated for incomplete rotator cuff tear or rupture of right shoulder. He notes persistent right shoulder pain and significant pain and weakness of the shoulder with overhead activity. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Therapy is noted to have been completed, but the dates and number of sessions are not noted. Furthermore, the actual magnetic resonance imaging report was not provided for review to corroborate the pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right shoulder surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right shoulder surgery (23430, 29828).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 20, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs/outpatient facility. The enrollee has been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $7,222.49 ($7,222.49 x 20% = $1,444.50). An injection falls within the Medicare Part B prescription drugs/outpatient facility benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy evaluation.

You asked the Plan to pre-approve the physical therapy evaluation. The Plan denied your request. The Plan says a physical therapy evaluation is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the physical therapy evaluation. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records the enrollee appears to have improved with therapy to the point of having minimal decrease in range of motion, minimal increase in strength recently and no recent improvement in pain level. Further skilled therapy at this point does not appear to be likely to achieve any significant further improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 physical therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve a physical therapy evaluation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you want to return to being independent. The Plan denied your request. The Plan says you do not need an intensive therapy program with multiple visits from a rehab doctor.

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 physician reviewer found that you were admitted to the acute care hospital for a compression fracture. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 9, 2020.
You asked the Plan to pay for the testing services. You say that biomarkers provide clinically actionable
information. The Plan denied your request. The Plan says the testing is experimental.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
We looked at the file and the rules. The medical records provided do not show that the results of the testing will
be used as part of the enrollee's treatment plan. The testing services were requested for screening purposes.
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have
to pay for the genetic testing provided on October 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta Suser 32 mg vial.
You asked the Plan to pre-approve Zilretta. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Zilretta. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found the Plan requires a trial of drug Dexamethasone and Triamcinolone before they will approve the requested drug. In this case, you have not tried and failed the required drug(s). There is no documentation indicating that the plan's required drug(s) would likely be less effective and/or likely 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta Suser 32 mg vial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on February 10, 2020 by an out of network provider.
You asked the Plan to pay for the podiatry services. You say that it is not the responsibility of the physician to request authorization. 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 podiatry services provided on February 10, 2020 by an out of network 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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar laminectomy. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulator (TENS) unit.
You asked the Plan to pre-approve the transcutaneous electrical nerve stimulator (TENS) unit. You say that this device is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met for the TENS unit.
The Plan must follow Medicare rules. Medicare rules say that the enrollee must be enrolled in an approved clinical study in order for a TENS unit to be approved for chronic lower back pain. We looked at the file and Medicare rules. The enrollee is not enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of the transcutaneous electrical nerve stimulator (TENS) unit have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulator (TENS) unit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided in addition to a basic service (99051) provided on October 10, 2020.
You asked the Plan to pay for services provided in addition to a basic service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99051 has a status indicator of B and is a bundled service.
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 99051 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99051 has a status indicator of B. This means that CPT code 99051 is a bundled code and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of services provided in addition to a basic service have not been met. Therefore, we decided that the Plan does not have to pay for services provided in addition to a basic service (99051) provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and advanced care planning provided by an
out-of-network provider on January 4, 2021.
You asked the Plan to pay for the office visit and advanced care planning. You say that the patient came in with
chronic conditions that needed to be reviewed. You say that you were not aware the patient had an HMO plan
at the time of service. The Plan denied your request. The Plan says this provider is not a network provider with
the Plan and the services were not approved in advance.
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
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 office visit and advanced care planning
provided by an out-of-network provider on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you are in support of this LTACH plan.
The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the 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 she is
currently receiving care. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110)
provided on December 28, 2020.

You asked the Plan to pay for the evaluation and cleaning. You say that you thought the December
appointment would be covered because you did not actually go to the July appointment. The Plan denied your
request. The Plan says they paid for a cleaning and periodic evaluation for you on July 31, 2020, which is less
than 6 months before the date in question. Oral evaluations and cleanings are only eligible for coverage once
every 6 months.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one oral
exam every 6 months and one cleaning every 6 months.

Though the Plan offers a dental benefit in excess of Medicare coverage, the evaluation and cleaning are
requested in a frequency not covered under this benefit. Documentation shows that the Plan was billed and paid
for a cleaning and evaluation in July of 2020. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation (D0120) and cleaning (D1110) provided on December 28, 2020.