Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on December 22, 2018.You asked the Plan to pay forthe services. The Plan deniedyour request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until January 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided on December 22, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Monovisc injection.

You asked the Plan to pre-approve a Monovisc injection. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria is met. 

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 Monovisc injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found due to too short a nature of conservative therapy, the services are not medically reasonable and 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 a Monovisc injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Monovisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a bi-level positive airway pressure
(BiPAP) device.
You asked the Plan to pre-approve the continued use of BiPAP. You say that the enrollee continues to require
the use of this device. The Plan denied your request. The Plan says Medicare coverage criteria for continued
use are not met at this time due to a lack of adherence to therapy.
The Plan must follow Medicare rules. Medicare rules say that in order to support adherence to BiPAP therapy,
objective evidence must be provided showing use for at least four hours on 70% of nights.
In this case, the compliance report does not show that the enrollee is using the BiPAP for at least four hours on
70% of nights. Without demonstrated adherence, continued coverage is not allowed. Therefore, we decided that
the Plan does not have to pre-approve continued use of a bi-level positive airway pressure (BiPAP) device.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at 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 IRFcare have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 medical services provided to you by an out-of-network provider on
October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 molecular testing provided on August 1, 2020.You asked the Plan to pay forthe molecular testing. You say that you would like reconsideration because this testing is medically necessary.The Plan denied your request. The Plan says this testing has not been billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the molecular testing have not been met. Specifically, this claim has not been billed correctly. Per Medicare rules, the appropriate CPT code for Guardant360 testing is 81479.Therefore, we decided that the Plan does not have to pay forGuardant360 molecular testing provided on August 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Planwas correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided daily skilled services are not required. You do not require theservices on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.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 care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an endodontist (D9310).
You asked the Plan to pre-approve a consultation with an endodontist. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 says covered services must be performed by a participating general dentist. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a consultation with an endodontist have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation with an endodontist (D9310).
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the thoracic spine without contrast (72146).You asked the Plan to pre-approvethis service. You say that an MRI of the thoracic spine is medically necessary for the enrollee.The Plan denied your request. The Plan says that an MRI of the thoracic spine is not medically necessary.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 this service. Our reviewer says that an MRI of the thoracic spine is not medically necessary. Our physician reviewer found that given the last note stating the patient is improving and that the patient has had a recent MRI of lumbar spine not showing lumbar stenosis, this study does not have enough documentation to warrant a repeat study.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 service have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the thoracic spine without contrast (72146).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the rib x-ray (71101), sacroiliac joint x-ray (72200), hand x-ray
(73130), knee x-ray (73562) and ankle x-ray (73600) provided on November 20, 2019.

You asked the Plan to pay for the x-rays. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted 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.

We find that CPT code 72200, 73130, 71101, 73562 and 73600 is not supported in the record. Specifically, the
documentation submitted does not include the number of views for each x-ray. There is insufficient
information to verify the billed services. Based on this information, we decided that Medicare rules for
coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the rib
x-ray (71101), sacroiliac joint x-ray (72200), hand x-ray (73130), knee x-ray (73562) and ankle x-ray (73600)
provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on July 21, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment.
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 $30
copayment for outpatient diagnostic tests/in-network/lab services.
You have been asked to pay $27.36 which is less than your copayment amount of $30 for lab work. Lab work
falls within the outpatient diagnostic tests/in-network/lab 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 lab work provided by a participating provider on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthoses
(L1833) provided to the enrollee on April 28, 2020.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says there is not valid proof of delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in
this case. The delivery date is after the date of service, but still before the date the order was signed. The record
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore,
we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthoses (L1833)
provided to the enrollee on April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
June 3, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture adjustment (D5410) and the
partial lower denture adjustment (D5422) provided on June 16, 2020.
You asked the Plan to pay for the dental services. You say that you feel that you were overcharged for the
services that you received. You say that you had false treatments. The Plan denied your request. The Plan says
there is an annual allowance of $2,600 for comprehensive dental services. The Plan says that the allowance had
been exhausted prior to this date of service.
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, there is an allowance of up to $2,600
for comprehensive dental services. The record shows that the Plan paid $524 for services provided on January
13, 2020, $1,342 for services provided on February 26, 2020, and $734 for services that you received on May
21, 2020, thus exhausting your benefit. Additionally, the Evidence of Coverage says that after plan paid
benefits for comprehensive dental services, you are responsible for the remaining costs. Therefore, we decided
that the Plan does not have to pay for the complete upper denture adjustment (D5410) and the partial lower
denture adjustment (D5422) provided on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInsertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, single level and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, second level.You asked the Plan to pre-approveInsertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, single level (22869) and  Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, second level (22870). You say that the enrollee needs this procedure to alleviate low back pain.The Plan denied your request. The Plan says this surgery is not supported because research has not found it to be helpful for the enrollee's condition.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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. High failure rates have been reported. There is no spinal instability. More research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and Insertionof Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not been met.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for surgical laparoscopy, with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy (58661) provided March 30, 2020.
You asked the Plan to pay for the laparoscopy. You say that resubmitting the claim with attached waiver of liability form signed. Please review for payment. The Plan denied your request. The Plan says that the provider ineligible to bill Medicare. Provider billed claim under a place of service 21 - inpatient hospital. CMS states Medicare does not pay for these claims.
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 must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. 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 has not provided sufficient information to justify the reason for the denial. There was no information provided to verify that the provider is ineligible. There is no information provided that the services were related to military services. The service was not provided at a VA Hospital. The hospital is a general, civilian hospital. There is no reason given that the cancer treatment provided would not be covered by Medicare if provided in a civilian hospital. Therefore, we decided that the Plan has to pay for surgical laparoscopy, with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy (58661) provided March 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the shoulder (73221).You asked the Plan to pre-approvean MRI of the shoulder. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 an MRI of the shoulder. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not reveal a detailed orthopedic exam and no red flags such as profound weakness, fever, trauma etc. are listed in the records. The enrollee has not been given a 6-week trial of monitored physical therapy. Therefore, medical necessity of MRI of the right shoulder has not yet beenestablished.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the shoulder have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the shoulder (73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on May 18,
2020.
You asked the Plan to pay for the dental service. You say that you were under the impression that the x-rays
were covered once every 5 years. You also say that the service should be covered. The Plan denied your
request. The Plan says the complete series of x-rays is not listed as a covered service.
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
complete series of x-rays (D0210) provided on May 18, 2020.