Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a brief emotional/behavioral assessment (96127) performed on March 1, 2021.

You asked the Plan to waive the copayment for an emotional/behavioral assessment. You say that this was not a specialist visit and there should have been no charge under your plan. The Plan denied your request. The Plan says the correct copayment was applied.

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 $40 copayment for each Medicare-covered outpatient mental health care individual or group therapy visit. 

You have been asked to pay a $12.07 copayment for an emotional/behavioral assessment. An emotional/behavioral assessment falls within the "Outpatient mental health care" benefit category. This means that you have been asked to pay less than or equal to 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 brief emotional/behavioral assessment (96127) performed on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that the request is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the
device is helpful for treatment of your health problem.

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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has lumbar spinal stenosis with neurogenic
claudication. Imaging demonstrates that there is multi-level severe spinal stenosis. The elements of the
coverage rule 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered soon when appropriate and when treatments are completed, and the enrollee is more stable hemodynamically.

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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve back surgery: right L3/4 microdiscectomy (CPT code(s): 63030, 63047).

You asked the Plan to pre-approve the surgery. You say that you are experiencing pain, loss of function, impeding cauda equina syndrome on L3 and L4. You state you have a loss of sensation and pain cannot be relieved without surgery. You state you are having trouble standing on that leg, cannot put any weight on the leg and if you do not get this surgery you lose your leg. The Plan denied your request. The Plan says that the clinical documentation does not show that you have had three (3) months of conservative treatment as described above within the past six (6) months.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have lumbar spinal stenosis with radiculopathy and neurogenic claudication. Imaging from June 2021 demonstrates intact hardware at the L4-L5 level without evidence of failure. There is severe central canal stenosis and severe right and moderate left foraminal stenosis. You have episodes of right leg heaviness and giving out and now requires an assistive device to ambulate. The totality of the documentation supports the medical necessity and reasonableness of the requested service. The elements of the coverage rule are satisfied. The requested service is recommended. 

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 surgery have been met. Therefore, we decided that the Plan has to pre-approve back surgery: right L3/4 microdiscectomy (CPT code(s): 63030, 63047).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis provided by an out-of-network provider on December 17, 2020.

You asked the Plan to pay for the arthrocentesis. You say that you received a bill. The Plan denied your request. The Plan says the provider is out-of-network and there is no authorization on file.

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 arthrocentesis provided by an out-of-network provider on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a group 3 powered wheelchair with multiple power options and various accessories.

You asked the Plan to pay for a group 3 powered wheelchair with multiple power options and various accessories. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a group 3 powered wheelchair with multiple power options will only be covered if the criteria for a power tilt seating system have also been met. 

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 pay for a group 3 powered wheelchair with multiple power options and various accessories. Our reviewer says that the requested group 3 power wheelchair with multiple power options is not medically necessary. Our physician reviewer found while the patient has a qualifying neurological disorder for a group 3 power wheelchair and has a mobility deficit unable to be effectively ameliorated by a cane, walker, or manual wheelchair due to coordination and balance issues, weakness, and shoulder subluxation, the patient does not require a group 3 power operated vehicle with multiple power options. The patient does not require a power tilt recline seating system (E1007, E1012). There is no evidence that the patient is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management or needs the power seating system to manage increased tone or spasticity. Because the base power wheelchair cannot be covered, the remaining accessories will be denied as not reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 powered wheelchair with multiple power options and various accessories have not been met. Therefore, we decided that the Plan does not have to pay for a group 3 powered wheelchair with multiple power options and various accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on October 12, 2020.

You asked the Plan to pay for the office visit. You say that records are attached to support the medical necessity. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 the office visit provided by an out-of-network provider on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for COVID 19 infection and respiratory failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower 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 LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically 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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services.
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 member is needing wound care and TPN care that the SNF does not handle. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical drainage of an abscess after recent abdominal surgery. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) and the topical application of fluoride (D1208) provided from February 2, 2021, to February 17, 2021.

You asked the Plan to pay for the complete series x-ray and the fluoride application. You say that you contacted the Plan for the name of a participating provider. You say that the plan representative gave you the name of a dental office and their phone number. You also say that now you are being told that the dentist you saw is out of network. The Plan denied your request. The Plan says topical application of fluoride is not listed as a covered service. The Plan says that 1 complete series x-ray or panoramic x-ray is covered every 3 years. The Plan also says that the frequency limit has 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, the topical application of fluoride is not among those covered under this benefit. Additionally, complete series x-ray shares a frequency limit with panoramic x-ray of once every 3 years. The record shows that the Plan paid for a complete series x-ray that you received on March 26, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) and the topical application of fluoride (D1208) provided from February 2, 2021, to February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested treatment is experimental/investigational.

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 procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that current evidence-based medical guideline and peer-reviewed literature do not
fully support the spinal decompression device procedure over the "gold standard" of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for
the enrollee's medical condition.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on December 29, 2020.

You asked the Plan to pay for a telehealth visit. You say that Medicaid has instructed providers to bill telehealth services with place of service code 12 for the enrollee's home. The Plan denied your request. The Plan says this service was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site. 

We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from January 8, 2021, through January 26, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

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 $0 per day, for days 1-20 and $125 per day, for days 21-100 for skilled nursing facility care rendered by an in-network provider.

You have been asked to pay $1,000 ($125 copayment x 8 days) for the inpatient skilled nursing facility care provided. You previously received 10 days of skilled nursing care in another facility from November 11, 2020, through November 21, 2020, which is part of this benefit period. 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 inpatient skilled nursing facility (SNF) care provided from January 8, 2021, through
January 26, 2021.