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

We decided that the Plan has to pay for telephone evaluation and management (99441) provided on June 2,
2020.
You asked the Plan to pay for the telephone evaluation and management. You say that you would like
reconsideration because you had a necessary telephone visit with your primary care provider. The Plan denied
your request. The Plan has not addressed your request.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the telephone evaluation and management by a contract provider. The file does not show
that the Plan provided notice that the telephone evaluation and management would not be covered. Under
Medicare rules, this means the telephone evaluation and management is considered approved by the Plan.
Therefore, we decided that the Plan has to pay for telephone evaluation and management (99441) provided on
June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two treatments of root canal obstructions, consultation, and endodontic therapy provided on October 22, 2020.
You asked the Plan to pay for the treatments of root canal obstructions, consultation, and endodontic therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says the treatment of root canal obstruction and consultation are not covered benefits. The Plan also says that your benefits for the endodontic therapy had been satisfied and the frequency limitation had been exceeded.
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, treatment of root canal obstruction and consultation are not among those covered under this benefit. The contract clearly states that root canals are limited to one procedure per calendar year. The record shows that you received two root canals on October 22, 2020, one of which was covered by the Plan, and your root canals benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two treatments of root canal obstructions, consultation, and endodontic therapy provided on October 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on August 31, 2020.
You asked the Plan to pay for Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (0012M). You say that the Plan should pay this claim. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnosis listed on the claim.
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, Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (0012M), 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 the laboratory test provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (CPT 41899, CPT 00170) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says dental work for infection is not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services (CPT 41899, CPT 00170) for the enrollee.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 is living at home and has progressive weakness and functional decline. Medical problems 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 it is felt that LTACH care would be best for this enrollee. The Plan denied your request. The Plan says this is not medically reasonable and necessary.
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 was admitted to the acute care hospital on 2/22/21 with perforated diverticular disease, with perforation and abscess formation. Sigmoidectomy with end colostomy and open appendectomy were performed. Post-operatively the enrollee went into alcohol withdrawal and suffered a respiratory arrest. The enrollee underwent tracheostomy. A pneumothorax developed and required decompression and a chest tube. The enrollee experienced dehiscence, and went for repeat abdominal exploration, washout of the abdomen, and surgical repair. Thoracentesis was performed on 3/3/21, and the chest tube was removed on 3/9/21. On 3/10/21 the enrollee was in no distress. Wound care is being continued. Oxygen is being weaned. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. 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 he 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that a stair lift is medically necessary. The Plan denied your request. The Plan says a stair lift is not a covered benefit under your contractual policy or by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate for you 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 stair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261).

You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because this is the only provider that has your hearing aids. The Plan denied your request. The Plan says you did not receive these hearing aids from the required provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from the provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, you did not receive your hearing aids from the Plan's provider. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a remote pacemaker evaluation.

You asked the Plan to waive the copayment for pacemaker test. You say that you should not be charged this copayment. 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 $20 copayment for in-network pacemaker test.

You have been asked to pay $20 copayment for pacemaker test. Pacemaker test 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 a remote pacemaker evaluation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder.

You asked the Plan to pre-approve MRI. You say that you want this MRI to check for active inflammatory arthritis. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because this MRI is not indicated.

The Plan must follow Medicare rules. Medicare rules say that MRI's 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for this MRI. Our physician reviewer found there is no recent trial and failure of physical therapy. The enrollee has seronegative arthropathy and MRI of the shoulder is not clinically indicated. More conservative measures for shoulder pain are needed. There are no red flags indicating a need for MRI 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve accu-chek fastclix lancets (A4259).
You asked the Plan to pre-approve accu-chek fastclix lancets. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation indicating you tried and failed a preferred glucose strip that is covered by your Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of accu-chek fastclix lancets have not been met. Specifically, there is no documentation indicating you tried and failed the Plan's preferred brand of diabetic supplies. This means the requested items are not covered. Therefore, we decided that the Plan does not have to pre-approve accu-chek fastclix lancets (A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 15, 2020, by an
OON provider.
You asked the Plan to pay for physician services. You say that you wanted to be seen right away because you
had a sore throat. The Plan denied your request. The Plan says prior authorization was not obtained by a
participating provider.
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 physician services provided on September 15,
2020, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit with prolonged services (99336, 99354) provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit. You say that these services were medically necessary. The Plan denied your request. The Plan says they do not cover out of network care except in limited circumstances. These services were not urgent or pre-approved. The enrollee's primary care physician did not provide a referral for this provider or 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 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 home visit with prolonged services (99336, 99354) provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta Sol 0.024% for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Vyzulta Sol 0.024% for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the collagen dressing (A6021) provided on October 30, 2019,
by an out-of-network (OON) provider.
You asked the Plan to pay for the collagen dressing. You say that this service was medically necessary. The
Plan denied your request. The Plan says they do not have out of network coverage for outpatient therapeutic
services and supplies, such as wound dressings. The services were not urgent or pre-approved.
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 collagen dressing (A6021) provided on
October 30, 2019, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D01330) and intraoral periapical images (D0230x5).

You asked the Plan to pay for the oral hygiene instructions and intraoral periapical images. You say that you would like reconsideration because you were not informed that this provider was no longer in-network. The Plan denied your request. The Plan says the oral hygiene instructions are not a covered benefit and the intraoral periapical images share the same frequency rate as another code that has been processed and paid.

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. Additionally, the record indicates that the Plan has agreed to reimburse you for CPT code an intraoral image coded D0220. Per your contract with the Plan, one intraoral x-ray is covered per calendar year. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D01330) and intraoral periapical images (D0230x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431) and the diagnostic casts (D0470).

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the adjunctive pre-diagnostic testing is not listed as covered under the routine dental benefit. The Plan says that the diagnostic casts are not listed as covered under the routine dental benefit either. The Plan also says that any services not listed 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431) and the diagnostic casts (D0470).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shank foot system.

You asked the Plan to pre-approve all lower extremity prosthesis, shank foot system with vertical loading pylon
(L5987). You say that the prosthesis will enable you to watch your kids and return to work part time. The Plan
denied your request. The Plan says there are no clinical findings presented to support the assertion that member
is a K3 ambulator.

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 all lower extremity prosthesis, shank
foot system with vertical loading pylon (L5987). Our reviewer says that the requested item is not considered
medically reasonable and necessary in this case. Our physician reviewer found based on the medical records
provided there is no documentation that the requested components are medically reasonable and necessary as
there is no independent clinical documentation that the enrollee is a K3 ambulator. Records indicate the
enrollee currently requires an assistive device to ambulate. Based on the medical records provided there is no
independent clinical documentation that the enrollee is a K3 ambulator. Records indicate the enrollee currently
requires an assistive device to ambulate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of all lower extremity prosthesis, shank foot system with vertical loading pylon
(L5987) have not been met. Therefore, we decided that the Plan does not have to pre-approve the shank foot
system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 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 laboratory services provided by an out-of-network provider.