Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services.You asked the Plan to pre-approvephysical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 physical therapy services. 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 the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that his functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, orthat the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed on a self-directedhome program. The requested services are not part of a maintenance program,and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says this Plan 
requires members to see in-network providers only, unless they have preauthorization from the Plan, the 
services requested are emergent in nature, or there are no other providers available to provide the services 
requested. There was no preauthorization from the provider on file. The clinical documentation provided 
reflects that the services provided were non emergent in nature and there are in-network providers available 
that could have provided the 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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70486) with 3D rendering (76376) provided on October 19, 2020.
You asked the Plan to waive the copayment for a CT scan with 3D rendering. You say that the Plan should pay more for these services. The Plan denied your request. The Plan says these services processed 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 $175 copayment for diagnostic radiological services such as CT Scans. You have been asked to pay a $154.51 copayment for a CT scan with 3D rendering because the allowed amount is less than $175. 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 computed tomography (CT) scan (70486) with 3D rendering (76376) provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided on 
April 22, 2020 to August 19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the home infusion therapy services. You say that the plan denied as not a Plan 
provider but you were referred by a plan representative. Please see other date of service that was processed and 
paid with the same procedure code. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. S codes 
are not payable by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The S codes (temporary codes) are used to report drugs, services and supplies for which there are no national 
codes. Private insurers for claim processing, policies or programs primarily use these codes. These codes are 
not payable by Original Medicare (OM). If original Medicare does not cover a service or a code, the Plan 
reserves the right to cover, but editing rules will be based on our guidelines, not original Medicare for that 
service or code. 
 
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 infusion therapy services (S9328) 
provided on April 22, 2020 to August 19, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvecontinuous glucose monitoring (CGM) supplies to be provided by an out of network (OON) durable medical equipment (DME) supplier.You asked the Plan to pre-approvethe OON CGM supplies. You say that you are requesting to be allowed to use an OON DME supplier due to the longstanding issues with timely delivery you have had with the DME supplier allowed by your medical group. YThe Plan denied your request. The Plan says that per your contract, you are only allowed to use network provider. Your medical group has one DME supplier which you must use. OON care can only be approved when the service is unavailable within the network. An unsubstantiated grievance you have with the network provider does not mean that OON care is medically necessary.The Plan must follow Medicare rules. Medicare rules say that Plans must arrange for OON care when network providers are inadequate to meet your medical needs.We have reviewed the Medicare rules and the documentation submitted by you and the Plan. We disagree with the Plan's determination that the issue with this provider is unsubstantiated. You have submitted detailed documentation showing the lag between when you are required to change your sensors and when the supplier has been able to deliver these to you. This documentation covers most of the 2020 calendar year and shows that this is a consistent issue. You have also provided documentation to support that when you run out of testing supplies, these supplies are urgently needed. You have shown that your bloodsugar has dropped to dangerous levels and that this would not be detectable when you have exhausted the supplies provided in the prior late delivery. Given this documentation, we find that there is sufficient evidence to conclude that the single DME supplier allowed for your medical group is not adequately meeting your needs.Therefore, we decided that the Plan has to pre-approvecontinuous glucose monitoring (CGM) supplies to be provided by an out of network (OON) durable medical equipment (DME) supplier.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic services provided on July 8, 2020 by an out of network (OON) provider.You asked the Plan to pay fordiagnostic services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 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 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 fordiagnostic services provided on July 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (20611) provided June 4, 2020.You asked the Plan to pay forthe surgical services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.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 20611 is Arthrocentesis, aspiration and/or injection, major joint or bursa; with ultrasound guidance.We find that CPT code 20611 is not supported in the medical record. Specifically, the record did not include any evidence of ultrasound imaging being performed. The plan requested copies of the imaging and none were provided. Based on this information, we decided that Medicare rules forcoverage of the surgical services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical services (20611) provided June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and an outpatient surgery provided on
August 31, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for physician services and an outpatient surgery. You say that there was a referral on
file since 2017. The Plan denied your request. The Plan says prior authorization was not on file. The Plan says
that these services were not referred by a network provider or rendered in a participating facility.
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 and an outpatient surgery
provided on August 31, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that the Plan has already approved a LDCT scan for the enrollee. An additional LDCT scan within the last year is non-covered. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement lead wires for use with a TENS unit 
provided on September 4, 2020. 
 
You asked the Plan to pay for the lead wires. You say that this should not be considered bundled in payment 
for any other code. The Plan denied your request. The Plan says there is no documentation showing the need 
for the replacement lead wires within the 12 month period. 
 
The Plan must follow Medicare rules. Medicare rules say that it would rarely be reasonable and necessary to 
replace lead wires more often than every 12 months.  
 
In this case, the replacement lead wires were provided 11 months after the rental of the TENS began on 
October 4, 2019. No documentation to support that the wires were medically necessary at the time they were 
provided was submitted. Therefore, we decided that the Plan does not have to pay for the replacement lead 
wires for use with a TENS unit provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has approved a total of 26 visits so far.
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 the additional 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 the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in a home exercise plan. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forechocardiography during rest and stress (93315) doppler echocardiography (93302) doppler color flow velocity mapping (93325) encounter for examination for driving license (Z02.4) provided May 8, 2020.You asked the Plan to pay forphysical exam and screening. You say that you feel that this should not be 100% your responsibility. You had talked to different people and was told this was coded incorrectly and should be rebilled.The Plan denied your request. The Plan says services required by a third party are not covered.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 physicalexam and screening have not been met.Therefore, we decided that the Plan does not have to pay forechocardiography during rest and stress (93315) doppler echocardiography (93302) doppler color flow velocity mapping (93325) encounter for examination for driving license (Z02.4) provided May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe sacroiliac joint injection.You asked the Plan to pre-approveinjection. You say that this shot will alleviate the member's symptoms and will help to avoid an intermediate risk injection.The Plan denied your request. The Plan says the records do not show there has been at least 2 months since the last shot.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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prior sacroiliac joint injection did not provide significant pain relief and the concept that a low risk injection will alleviate the need for a higher risk injection is not evidence based.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection have not been met.Therefore, we decided that the Plan does not have to pre-approvethe sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the right wrist brace provided on June 23, 2020.

You asked the Plan to pay for the wrist brace. You say that the documentation supports the medical necessity of this brace. The Plan denied your request. The Plan says that this claim is a duplicate of one that was already paid.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The file shows that this claim was denied due to payment already having been made for the item at issue previously. However, the file does not include any evidence to show that payment had been made for the code L3916-RT-KX. Without any confirmation that payment has in fact been made, we find that the denial of this claim is not supported. Therefore, we decided that the Plan has to pay for the right wrist brace provided on June 23, 2020. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex device.You asked the Plan to pre-approvea Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with lumbar spinal stenosis with neurogenic claudication. The requested spacer is experimental. More research is needed to show safety and efficacy. Hardware is not needed in this enrollee with no spinal instability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more fortwo crowns (D2740) provided on September 1, 2020.You asked the Plan to pay more forthe dental services. You say that you had twocrowns done last year with a $0 copayment. You say that you had twomore crowns done this year and the Plan only paid 30%. You also say that you were not notified of the drastic change in coverage.The Plan denied your request. The Plan says there is a 30% coinsurance for crowns. The Plan says that the Annual Notice of Changes (ANOC) for 2020 was mailed in September 2020. The Plan says that the ANOC shows that the previous dental coverage would be replaced with a differentdental coverage.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, there is a 30% coinsurance for crowns that you receive in network. Coinsurance This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to pay more fortwo crowns (D2740) provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on June 25, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you know that this service was not listed in your EOC. You also say that you would like to be reimbursed for this service. The Plan denied your request. The Plan says this service is not covered. The Plan also says that no calls were received from you prior to the services being rendered.
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 comprehensive periodontal evaluation (D0180) provided on June 25, 2020.