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

We decided that the Plan does not have to pre-approve psychiatry care to be provided by an out-of-network
provider.

You asked the Plan to pre-approve out-of-network psychiatry care. You say that the doctor stated you need
outside therapy to help with coming from a narcissistic environment. You say that you will continue to decline
without help from this therapist. The Plan denied your request. The Plan says care is available in-network.

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
psychiatry care to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network neurologist.

You asked the Plan to pre-approve the out-of-network office visit. You say that this is the doctor who was
recommended by the previous neurologist. The Plan denied your request. The Plan says the service requested
can be safely rendered in-network.

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
the office visit with an out-of-network neurologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that the enrollee cannot be left alone. The Plan
denied your request. The Plan says the enrollee no longer requires daily skilled services.

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.

The file shows that continued SNF services beyond June 18, 2021, were requested. 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 continued services. Our physician reviewer found that from a
nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable
skilled nursing service needs. Regarding rehab services, the enrollee is independent with functional mobility.
She requires varying assist with activities of daily living. There are no identifiable skilled therapy service
needs. She does not require skilled nursing or therapy services on a daily basis. She does 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E1012, E2311) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says CPT codes E1012 and E2311 remain denied because these are for two or more power seating system motors and are not required to operate the group 2 single power wheelchair with power tilt.

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 the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not show the presence of severe lower extremity edema or the presence of a musculoskeletal condition preventing 90 degrees of knee flexion, therefore the request for the power elevating leg rests is not supported. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The upgraded electronic (E2311) which is for two or more power seating system motors is not required to operate the group 2 single power wheelchair with power tilt. The additional power wheelchair accessories (E1012, E2311) are not medically necessary as the items exceed the enrollee's medical need.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E1012, E2311) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.

You asked the Plan to pre-approve the implants. You say that you would like the dental implants to be approved for coverage. The Plan denied your request. The Plan says these services are not covered.

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 dental implants.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 30, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #18.

You asked the Plan to pre-approve the crown. You say that the root canal in this tooth is asymptomatic and free
of inflammation and infection, and this crown is necessary. The Plan denied your request. The Plan says there
is a clinically unacceptable root canal fill on this tooth. The obturation material is short of the apex, and there is
periapical radiolucency associated with the root. Criteria for a crown on tooth #18 is not 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 covers the crown
when the services are medically necessary and reasonable.

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 crown. Our reviewer says that the
criteria for a crown for tooth #18 has not been met. Our physician reviewer found that the tooth in question has
been endodontically treated, however the root canal fill appears to be more than several millimeters short of the
apex of the tooth, making the long-term prognosis poor. When the fill is short, bacteria remain in the canals,
and symptomatic reinfection is likely to recur. A permanent restoration such as a crown should not be
completed until such time the root canal system is properly shaped and cleaned with the sealer in close
proximity to the apex of the root. As the root canal fill appears to be inadequate to ensure a good long-term
prognosis, a crown is not indicated at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2750) for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says there was minimal improvement with prior injections.

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 the injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that in this case, the records indicate that the enrollee has a new left paracentral disc extrusion
at L4-L5 compared to previous studies. The enrollee had injections of L4-L6 over two years ago with 40% and
10% relief. The enrollee previously participated in physical therapy and now desires to again. The medical
record does not indicate that there is significant functional loss at home or work. The medical record does not
indicate that there is an inability to tolerate non-surgical, non-injection therapies. The medical record does not
indicate that there have been previously successful injections. The elements of the coverage rules are not
satisfied.

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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar epidural injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 13, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon services are not payable for this code.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 58558. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on August 25, 2020.

You asked the Plan to waive the coinsurance for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your coinsurance amount was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a 35% coinsurance for the laboratory services. The approved amount for the services rendered is $527.78. 35% of $527.78 is $184.72. The laboratory services fall 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 coinsurance for laboratory services provided on August 25, 2020.

If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.

You asked the Plan to pre-approve the office visit. You say that you are appealing this denial. The Plan denied
your request. The Plan says the provider is out-of-network.

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
the office visit to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (77063, 77067) provided November 18, 2019.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be processed until an explanation of benefits is received from the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to obtain an explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the radiology services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for radiology services (77063, 77067) provided November 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 14021 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 14021 is adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm. 

We find that CPT code 14021 is not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement of scalp, 10.1sq cm to 30.0sq cm. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on December 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can be met in the skilled nursing facility setting.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a thoracic compression fracture. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the CT scan. We decided that the Plan does not have to pre-approve the CT of pelvis.

You asked the Plan to pre-approve the CT scan. You say that the enrollee has a history of pancreatic cyst that requires yearly monitoring. This is required to make sure that the cyst remains stable and will not require further intervention. The Plan says that the enrollee received this study in January 2021 while hospitalized. The Medicare NCD criteria are not met as the current request for abdomen and pelvis CT is duplicative.

We decided that the Plan has to pre-approve the CT of abdomen.

We also decided that the Plan does not have to pre-approve the CT of pelvis.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the enrollee partially meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has a history of a pancreatic cyst. The enrollee underwent a CT scan in January of 2021. However, this study was performed without contrast and is insufficient to provide the necessary follow up for a pancreatic cyst. A repeat CT scan of the abdomen is medically necessary and reasonable, as defined by Medicare rules, given the clinical scenario. A CT of the pelvis is not medically necessary and reasonable, as defined by Medicare rules, given the clinical scenario. The CT of the abdomen is recommended whereas the CT scan of the pelvis cannot be recommended at his 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 CT scan of abdomen have been met and the Medicare rules for coverage of the CT of pelvis have not been met. Therefore, we decided that the Plan has to pre-approve the CT of abdomen and does not have to pre-approve the CT of pelvis.

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.