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

We decided that the Plan does not have to pre-approve plastic surgery consultation and follow-up to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve plastic surgery services. You say that the Plan is horrible, and you did not receive any of these services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve plastic surgery consultation and follow-up to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on February 5, 2021.

You asked the Plan to waive the copayment for EKG. You say that this has always been part of your annual physical. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $10 copayment for EKG.

You have been asked to pay $10 copayment for EKG. EKG 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 an electrocardiogram (EKG) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON ophthalmology services. The Plan denied your request. The Plan says there are in-network ophthalmologist who can treat the enrollee.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) rhythm testing provided on November 16, 2020, billed with code 93042.

You asked the Plan to pay for the ECG rhythm testing as billed. You say that the services were medically necessary and should be paid as billed. The Plan denied your request. The Plan says code 93042 is not separately payable in this case.

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 93042 is Rhythm ECG, 1-3 leads; interpretation and report only. 

We find that CPT code 93042 is not supported in the medical record. Specifically, the record only documents one interpretation/report of an ECG. Monitoring of ECG rhythm is not separately reportable. There is no evidence that a diagnostic rhythm test was performed. Based on this information, we decided that Medicare rules for coverage of the ECG rhythm testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) rhythm testing provided on November 16, 2020, billed with code 93042.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is in an acute inpatient hospital that can provide acute care needs.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist visit. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a dermatology consultation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Galilean Telescope device.
You asked the Plan to pre-approve a Galilean Telescope device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a Galilean Telescope device is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover low vision aids.
The services you asked the Plan to pre-approve are considered low vision aids. Medicare excludes coverage of low vision aids, which includes all devices that use one or more lenses to aid vision or magnify images. Therefore, we decided that the Plan does not have to pre-approve a Galilean Telescope device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
March 24, 2021.

You asked the Plan to pay an additional amount for the eyeglasses. You say that The Plan denied your request. The Plan says the full routine vision hardware allowance was applied to the claim.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has paid the full routine vision hardware allowance of $100. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered meals.

You asked the Plan to pre-approve the meals. You say that this is needed after ambulatory hand surgery. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. There is a plan supplemental benefit for these meals, but there is a requirement for discharge from inpatient status, which is not documented for this case. Therefore, we decided that the Plan does not have to pre-approve home delivered meals.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #3.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 core buildup (D2950) for tooth #3.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on November 19, 2020, by an in-network ambulatory surgical center.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that it has been five (5) years since your first colonoscopy and all were paid with no deductible for a diagnostic colonoscopy procedure. You state you were not told the colonoscopy was for diagnosing pain. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the diagnostic colonoscopy on November 19, 2020, by an in-network ambulatory surgical center. You have a history of colonic polyps and there were other findings that would not make this colonoscopy a screening. You were asked to pay a $225 copayment for the diagnostic colonoscopy. Your 2020 EOC states that enrollees must pay a $225 copay for all other services in an Ambulatory Surgical Center (including diagnostic colonoscopy). 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 the diagnostic colonoscopy provided on November 19, 2020, by an in-network ambulatory surgical center.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on May 9, 2020.

You asked the Plan to pay for the therapeutic activities. The Plan denied your request. The Plan says that the
documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and the Medicare rules. The file shows that you did not submit sufficient information to
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic activities provided on May 9, 2020.
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 the enrollee does 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. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's 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 in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. 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 covered benefit.
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 laboratory services provided on February 24, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a vision exam provided on
January 2, 2021.
You asked the Plan to waive the coinsurance for the vision exam. The Plan denied your request. The Plan says the visit processed under your Medicare-covered vision exam benefit appropriately.
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 20% coinsurance for vision care, Medicare covered exams. You have been asked to pay 20% coinsurance for the vision exam. The vision exam falls within the vision care, Medicare covered exams 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 coinsurance for a vision exam provided on January 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81328, 81408, 81230, 81231, 81232, 81350, 81283, 81479, and 81335) provided to the enrollee on September 4, 2020, by non-participating provider.
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 Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The enrollee had molecular pharmacogenetic testing. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two, or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for panel. Diagnoses: I25.10 - Atherosclerotic heart disease of native coronary artery without angina pectoris, F31.30- Bipolar disorder, current episode depressed, mild or moderate Medicare denies coverage for all cardiovascular risk assessment testing/panels, except for the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81328, 81408, 81230, 81231, 81232, 81350, 81283, 81479, and 81335) provided to the enrollee on September 4, 2020, by non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you can continue to receive appropriate intensive rehab services at the inpatient rehab facility.

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 services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, your lungs were clear, and your diabetes was controlled. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a moderate assist level for transfers, and maximal assist for ambulation. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. You say that the additional PT should be covered because you have been improving. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The therapist notes that the therapy would now focus on cervical spine but there is no documentation of a physician follow up for cervical spine issues which appear may be radicular in etiology that indicate a need for ongoing skilled physical therapy. 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 additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81404,
81406, 81479) provided to the enrollee on December 18, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the testing have not been met. Review of the file shows the
enrollee had cardiovascular risk assessment testing on December 18, 2020. The denial remains upheld as noncovered
as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel,
for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the
Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81404, 81406, 81479)
provided to the enrollee on December 18, 2020.