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

We decided that the Plan does not have to waive the copayment for the three crowns (D2750) provided on
March 9, 2021.
You asked the Plan to waive the copayment for the crowns. You say that you would like to appeal these
services. The Plan denied your request. The Plan says your copayment was applied according to your benefit
and remains your responsibility to pay.
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, you are responsible for a a $125
copayment per tooth for covered porcelain/stainless steel crowns. Therefore, we decided that the Plan does not
have to waive the copayment for the three crowns (D2750) provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), removal of residual tooth roots (D7250), placement of intra-socket biological dressing (D7922), and consultation (D9310) provided on July 14, 2020.

You asked the Plan to pay for the preventive procedure, removal of residual tooth roots, placement of intra-socket biological dressing, and consultation. You say that you and your provider spoke with the Plan prior to receiving these services and were advised the procedure would be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that your provider was given specific procedure code benefits from your dental plan and faxed a copy of the covered procedures.

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 preventive procedure (D1999), removal of residual tooth roots (D7250), placement of intra-socket biological dressing (D7922), and consultation (D9310) provided on July 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on July 17, 2020.
You asked the Plan to pay for therapeutic activities. You say that this should be covered at the in-network level. The Plan denied your request. The Plan says this was not billed correctly.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the record shows that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met.
Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on July 17, 2020.
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 IRF care is needed to improve strength, endurance, activities of daily living, and mobility. You say that the enrollee has medical needs that necessitate the daily medical oversight that would be provided in an IRF. You say that the enrollee is motivated to improve and will tolerate the three hours of therapy required of acute rehab. The Plan denied your request. The Plan says IRF care is not medically necessary.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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. The enrollee's medical conditions 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, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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-approve acute inpatient rehabilitation facility (IRF) admission and services
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 your acute days are being limited and you need to be released to an LTACH. You say that you cannot be sent home. You say that your gut malformation does not allow you to process or keep down food. The Plan denied your request. The Plan says the records do not show that the enrollee's pain is adequately controlled. The Plan says that the enrollee needs to stay in the hospital until she is better.
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 acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.
The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections.
You asked the Plan to pre-approve therapeutic facet joint injections. You say that this request is medically
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint injections are only covered
when the enrollee has had two diagnostic facet joint injections.
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 therapeutic facet joint injections. Our
reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer
found This 89-year-old woman has chronic right sided neck pain. She tried physical therapy and takes Tylenol
for pain. The request is for therapeutic facet injections. She has not had 2 sets of diagnostic facet
injections. Therefore, the requirements of the LCD are not met, and the request is deemed not 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 therapeutic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious disease (bacterial or viral respiratory tract infection), 22 targets (CPT code 0202U) provided to the enrollee on November 23, 2020.
You asked the Plan to pay for the screening. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit.
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 test at issue in this appeal, the screening, 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 for infectious disease (bacterial or viral respiratory tract infection), 22 targets (CPT code 0202U) provided to the enrollee on November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transport.
You asked the Plan to pre-approve non-emergency ambulance transport. 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 non-emergency ambulance services may be covered under certain circumstances. 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 non-emergency ambulance transport. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided records did not clearly show that the enrollee met the LCD criteria for this service as there was no contraindication for other means of transportation for this non-emergent transport and the enrollee was stable. Therefore, this request for ambulance services will be considered not medically necessary 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 non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transport.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87633, 82495, 82300,
82175, 83825, 83655, 87486, 87581, 84202 and 84402) provided to the enrollee on June 19, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
These services are not authorized because predictive screening testing is not a Medicare benefit. CPT code
87486 (1 unit) remains not supported. The documentation submitted did not include lab results for this test
from the billing provider; therefore, the billed service cannot be verified. It is noted that multiple attempts were
made to contact the provider for additional information. CPT code 87581 (1 unit) remains not supported. The
documentation submitted did not include lab results for this test from the billing provider; therefore, the billed
service cannot be verified. CPT code 84402 (1 unit) remains not supported. The documentation submitted did
not include lab results for this test from the billing provider; therefore, the billed service cannot be verified. It is
noted that multiple attempts were made to contact the provider for additional information. CPT code 84202 (1
unit) remains not supported. The documentation submitted did not include lab results for this test from the
billing provider; therefore, the billed service cannot be verified. Therefore, we decided that the Plan does not
have to pay for the laboratory services (CPT code(s): 87633, 82495, 82300, 82175, 83825, 83655, 87486,
87581, 84202 and 84402) provided to the enrollee on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular monitoring services (93226) provided on February 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the cardiac monitoring services. You say that you are asking the plan to redetermine this claim on the grounds that neither the doctor nor you knew that this this would need a prior authorization. This was a STAT echo and what was done was a necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the cardiovascular monitoring services (93226) provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for repair/modification of a hearing aid provided on
January 15, 2021.
You asked the Plan to pay for repair/modification of a hearing aid. The Plan denied your request. The Plan says hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though repair/modification of a hearing aid may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of services. Therefore, we decided that the Plan does not have to pay for repair/modification of a hearing aid provided on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on March 6, 2021, by an out of network (OON) provider.

You asked the Plan to pay for drug testing. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 records provided for review also show that the enrollee was referred by a non-participating provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 drug testing (80307, G0483) provided on March 6, 2021, by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.

You asked the Plan to pre-approve Hymovis. 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 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 Hymovis. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the somatosensory testing provided on December 28, 2020.

You asked the Plan to pay for the somatosensory testing (95938). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed place of service is not supported and payment for this service is included in payment to the facility and not separately reimbursable.

The Plan must follow Medicare rules. Medicare rules say that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. 

Since the mobile unit is serving an entity for which a facility POS already exists the code for that location should be reported. We find that this procedure code is not separately payable in the facility setting. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing (95938) have not been met. Therefore, we decided that the Plan does not have to pay for the somatosensory testing provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on February 5, 2021.

You asked the Plan to pay for the dental service. You say that it was discovered that there was a cavity under a pre-existing cap. You say that the old cap had to be removed to fix the cavity and the replaced with a new one. You also say that you do not understand why this is not covered. The Plan denied your request. The Plan says porcelain crown 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 porcelain crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 10, 2021 by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that the book says there is no copayment for 2 cleanings per year. The Plan denied your request. The Plan says this claim processed correctly.
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, you are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 10, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Mag-Al Plus and Potassium Chloride provided on March 13, 2021.
You asked the Plan to pre-approve the Mag-Al Plus and Potassium Chloride. The Plan denied your request. The Plan says these drugs are self-administered and are not covered.
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 the Mag-Al Plus and Potassium Chloride provided on March 13, 2021.
Benefits for the Mag-Al Plus and Potassium Chloride 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively
provide medically necessary and reasonable treatment 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 at this time and requires acute
medical management still. As a practical matter, at this time you do not require the necessary services on an
inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.