Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the legs for the enrollee.

You asked the Plan to pre-approve a CTA scan. You say that a CTA scan is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that CTA scans 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 a CTA scan. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found review of the records, in particular the most recent clinical visit of December 15, 2020 indicates the enrollee has difficulty walking. The physical exam does not include assessment of lower extremity pulses, especially Posterior Tibial and Dorsalis Pedis pulses and no evaluation of lower extremity reflexes. The notes describe a normal Ankle-Brachial Index ultrasound in the past but there is no date and no report included. Absent a detailed clinical assessment of the neurological status of the lower extremities as well as peripheral pulses in addition to a recent ABI the medical necessity of CTA has not been established in the records provided. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the legs for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary and provided in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 medical services provided on July 14, 2020 by an out of network (OON) provider.
Sincerely,
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a mammogram provided on June 22, 2020.

You asked the Plan to waive the copayment for a mammogram. You say that you have never had to pay in the past and disagree with the charges. 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 $20 copayment for X-rays and ultrasounds. 

The record shows that you a mammogram screening on June 18, 2020. Therefore, the mammogram you received on June 22, 2020, is considered diagnostic, not preventative, and you are responsible to pay the $20 copayment. 

You have been asked to pay a $20 copayment for a mammogram. A mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a mammogram provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections for the enrollee.

You asked the Plan to pre-approve this treatment. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of injection. 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 this treatment. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer said that based on the medical records provided, there are other probable pain generators, therefore, this request does not meet the criteria of the LCD. The requested procedures are not shown to be medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that although no authorization was obtained, you would like these services reconsidered. The Plan denied your request. The Plan says unauthorized, non-plan care is 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 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 medical services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe molecular testing provided on August 6, 2020.You asked the Plan to pay forthe molecular testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a coveredbenefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The molecular testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe molecular testing provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility services provided to the enrollee on August 20, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these are out-of-network services provided without 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 has network providers available who can provide 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 nursing facility services provided to the enrollee on August 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95885 and 95908 are not supported.
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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95908 is nerve conduction studies; 3-4 studies. We find that CPT codes 95885 and 95908 are not supported in the medical record. Specifically, there is no documentation of limited needle electromyography to support code 95885. There is no documentation of 3-4 nerve conduction studies to support code 95908. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on July 29, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that you feel like the hospital is greedy. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery.You have been asked to pay a $250 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on July 29, 2020. We note your complaint about prior issues that lead to this surgery. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
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 LTACH is medically necessary. The Plan denied your request. The Plan says there is no need to transfer from the current setting.
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 patient is a female who was admitted to the current acute care hospital with acute on chronic respiratory failure, COVID-19 pneumonia, and COPD exacerbation requiring oxygen, breathing treatments, and steroids. She was also treated for anemia with transfusion and epoetin alfa. She has since improved significantly. The patient appears to be improving but requires only short term additional acute care services which can safely be performed at the current facility. The patient does not require any services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Ongoing treatment at the current facility is appropriate until the patient is able to be transferred to a lower 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost forthe EKG interpretation, endoscopy and tissue exam provided on August 3, 2020.You asked the Plan to waive the cost forthe EKG interpretation, endoscopy and tissue exam. You say that you were given incorrect information resulting in costs for the procedures. You say that you are upset the claims weren't fully covered.The Plan denied your request. The Plan says the cost share applied 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 saysthat you must pay a $10 copayment for primary care physician services, a $200 copayment for ambulatory surgical center and outpatient hospital visits and 10% coinsurance for laboratory tests.You have been asked to pay a total of $216.01 for the EKG interpretation, endoscopy and tissue exam.The EKG interpretation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The tissue exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost forthe EKG interpretation, endoscopy and tissue exam provided on August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay forparamedic intercept services provided to the enrollee on July 13, 2020.You asked the Planto pay forthe services. You say that this should be paidfor.The Plandenied your request. The Plansaysthis is not a covered service.The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plandoes not haveto pay forparamedic intercept services provided to the enrollee on July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for theunspecified preventive procedure, by report (D1999) provided on July 2, 2020.You asked the Plan to pay for theunspecified preventive procedure. You say that the services were medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit of this Plan.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 theunspecified preventive procedure, by report (D1999) provided on July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 18, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe lab services. You say that this lab is contracted with the facility where the member resides.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that the lab that provided these services, the ordering provider, and the facility where the member resides are all out-of-network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The  provider 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 forthe lab services provided on August 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee out of network on July 27, 2020.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 fordrug testing provided to the enrollee out of network on July 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491, and 64492).
You asked the Plan to pre-approve facet joint injections. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for authorization and the service is therefore, not medically necessary.
The Plan must follow Medicare rules. The rules a second confirmatory MBB is allowed if documentation indicates the first MBB produced > 80% relief of primary (index) pain and duration of relief is consistent with the agent employed. Injections may be repeated if the first injection results in significant pain relief (>50%) for at least 3 months. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Specifically, the medical records do not show 80% relief of primary pain or >50% for at least 3 months. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64490, 64491, and 64492).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services.