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

We decided that the Plan has to pre-approve an in-network exception for a consultation with an out-of-network provider.
You asked the Plan to pre-approve the in-network exception. You say that you would like reconsideration because the recommended in-network provider is 2 hours away. The Plan denied your request. The Plan says that an out-of-network provider will not be paid at the in-network rate unless your condition is considered emergent or urgent.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The provider is a non-contract provider. We were able to confirm that the Plan's recommended contract provider is not located within reasonable distance and travel time from your home who can provide the in-network exception. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve an in-network exception for a consultation with an out-of-network provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lisinopril.You asked the Plan to pre-approve the Lisinopril. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered under the member's Medicare Part B Plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Lisinopril.Benefits for the Lisinopril may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you have been dizzy and are afraid to take a shower and cannot get in and out of the tub.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on September 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records, therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injections.
You asked the Plan to pre-approve the lumbar facet joint injections. You say that this treatment should be allowed so that the enrollee can possibly avoid spinal surgery. The Plan denied your request. The Plan says the criteria for this injection are not met.
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the above criteria are 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 the lumbar facet joint injections. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with chronic low back pain. The progress notes document twice that there is radiation of the pain into the left leg. She is taking methocarbamol and has tried an epidural injection and has had physical therapy. Since the patient has documented radicular pain, the criteria for the LCD are not met. The requested facet joint injections are not medically 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 the lumbar facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused, deep sedation
and unspecified adjunctive procedure provided on January 24, 2020.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that these are not
covered services.
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
limited oral evaluation - problem focused, deep sedation and unspecified adjunctive procedure provided on
January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services coded 20610 and the Dexamethasone sodium phosphate injection coded J1100 provided on December 12, 2019.
You asked the Plan to pay for the arthrocentesis services and the Dexamethasone sodium phosphate injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 20610 and J1100 are not supported in the medical record. Specifically, the medical records submitted appear to have been altered. An addenda was submitted and the change does not meet criteria set forth by CMS as the original content was not signed by the author. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis services and the Dexamethasone sodium phosphate injection have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis services coded 20610 and the Dexamethasone sodium phosphate injection coded J1100 provided on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprefabricated post and core in addition to a crown on teeth #14 and 30 (D2954).You asked the Plan to pre-approveprefabricated post and core in addition to a crown on teeth #14 and 30. 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 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 prefabricated post and core in addition to a crown on teeth #14 and 30. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it does not appear that endodontic treatment had been performed on tooth #14 or #30 given the provided records. The supplied x-rays clearly show that endodontics had not been initiated, however a treatment note for #19 indicated that root canal treatment was a possibility given increased symptoms after a crown preparation. Posts cannot be placed in teeth that have not had endodontic treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prefabricated post and core in addition to a crown on teeth #14 and 30 have not been met.Therefore, we decided that the Plan does not have to pre-approveprefabricated post and core in addition to a crown on teeth #14 and 30 (D2954).
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 IRF level care is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 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 while the enrollee may benefit and participate in multiple therapies, her functional level does not require this on an 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on February 10, 2020 from a non-Medicare provider.
You asked the Plan to pay for the eyewear. You say that Medicare should cover the cost of the glasses due to cataracts. The Plan denied your request. The Plan says you chose to go to a supplier who does not participate in Medicare, they are responsible for any charges over the Medicare rate. The Plan states that they cannot reimburse Medicare covered services at an amount any greater than Medicare would reimburse a Medicare supplier.
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. Review of the file show that you purchased the eyewear on February 10, 2020 from a non-Medicare provider. The provider does not participate with Medicare. Medicare guidance says to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. 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 the eyewear purchased on February 10, 2020 from a non-Medicare provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 6, 2019.You asked the Plan to pay forthese services. You say that youdisagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (CPT Code 92004) provided on January 9, 2020 by an out-of-network provider.You asked the Plan to pay forthe services. You say that you were told by the provider's office they were participating with the Plan.The Plan denied your request. The Plan says you do not have out-of-network benefits.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-approvethe 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 forophthalmological services: medical examination and evaluation with initiation ofdiagnostic and treatment program; comprehensive, new patient, 1 or more visits (CPT Code 92004) provided on January 9, 2020 by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora physical therapy evaluation (97163) provided on August 14, 2019.You asked the Plan to pay for the physical therapy evaluation. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says billed code does not appropriately reflect the services provided by the physical therapy assistant.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 97163 is  physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the physical therapy evaluation. Our reviewer says that CPT code 97163 is a reporting code for a Physician or other qualified healthcare provider. Our reviewer found a physical therapy assistant is not considered a qualified healthcare provider for this code.We looked at this coder'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 pay fora physical therapy evaluation (97163) provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 2, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for lab services. You say that you conducted these services in good faith. The Plan
denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's
primary care physician did not refer these services.
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 lab services provided on January 2, 2020 by an out
of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical dental extractions with sedation and drug application (D9222, D7210, D9612, D9223).You asked the Plan to pre-approve the extractions and related services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services requested are not a benefit that is covered by the Plan or Medicare.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 pre-approve surgical dental extractions with sedation and drug application (D9222, D7210, D9612, D9223).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on October 12, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 43659 is 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 43659 is unlisted laparoscopy procedure, stomach.We find that CPT code 43659 is not supported in the medical record. Specifically, the file shows that a laparoscopic gastrostomy was performed and there is a more specific code for these services. 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 forthe surgical services rendered on October 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 PWC with multiple power options and attachments.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that you do not meet medical necessity criteria for a Group 2 power wheelchair.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 power wheelchair with multiple power options are covered if the above criteria have been 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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not support that your physician or physician provider medical progress notes indicate physical exam evidence of lower extremity edema, hypertonicity or spasticity, or that you use intermittent catheterization. You are able to weight shift assisted. You do not require the tilt and recline power seating system. Our physician reviewer found that your condition does not meet Medicare criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 2 PWC with multiple power options and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a series of three epidural steroid injection (ESIs).
You asked the Plan to pre-approve the series of three injections. You say that the enrollee has radicular pain and should be allowed to try this ESI. The Plan denied your request. The Plan says a single ESI has been approved but more than one ESI cannot be pre-approved until the results from the first ESI are documented.
The Plan must follow Medicare rules. Medicare rules say that there is no role for a series of three for ESIs. Repeat ESIs can only be approved based on the response to prior injections. In this case, more than a single injection cannot be approved until the response to the approved injection. Therefore, we decided that the Plan does not have to pre-approve a series of three epidural steroid injection (ESIs).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 18, 2019 to July 26, 2019.
You asked the Plan to pay for SNF care. You say that the enrollee still needed skilled services. The Plan denied your request. The Plan says SNF care was no longer necessary.
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 pay for SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the patient did not 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 during the dates from July 18, 2019 to July 26, 2019. This patient's functional level did not need skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. 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 pay for skilled nursing facility (SNF) care provided from July 18, 2019 to July 26, 2019.