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

We decided that the Plan does not have to pre-approve chiropractic spinal manipulation.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found there are no imaging studies in the submitted documentation to show that you have a subluxation of the spine. The exam does not show any evidence of a subluxation of the spine. Chiropractic spinal manipulation is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic spinal manipulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from October 11, 2019 to November 16, 2019.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 rules also say that the number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Medicare reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purpose. We find that 36 units of inpatient services are not supported in the medical record. Specifically, 36 days of inpatient services were billed, however, only 35 days were provided as the discharge day does not count as an inpatient day. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from October 11, 2019 to November 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain patches and ear seeds.
You asked the Plan to pre-approve pain patches and ear seeds. You say that you can't go to your acupuncture because of COVID-19. The Plan denied your request. The Plan says that these are not covered services.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and pain patches and ear seeds are OTC items. Therefore, we decided that the Plan does not have to pre-approve pain patches and ear seeds.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder/arm orthosis provided to the enrollee on December 6, 2019.You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed supply code cannot be verified.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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a physical examination of the shoulder. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the orthosis.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay for the shoulder/arm orthosis provided to the enrollee on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit provided on June 26, 2019.
You asked the Plan to pay for the outpatient clinic visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 services at issue. 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 an outpatient clinic visit provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ear wax removal (69209) provided on November 21, 2019.You asked the Plan to pay for ear wax removal. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 69209 has been billed with an inappropriate place of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 69209is not supported in the record. Specifically, CPT code 69209 has a PC TC indicator of 5. This indicator identifies codes that are incident to physician services and are not eligible for separate payment when provided to hospital inpatients or patient's in the hospital outpatient department. Based on this information, we decided that Medicare rules for coverage of ear wax removal have not been met.Therefore, we decided that the Plan does not have to pay for ear wax removal (69209) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit rendered on December 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99203 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 99203 is new patient office or other outpatient visit, typically 30 minutes.We find that CPT code 99203 is not supported in the medical record. Specifically, the records show that an evaluation and management code was billed for this physician group within the past three years for the enrollee; therefore, a new patient office visit does not apply. 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 forthe office visit rendered on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the home visit provided on December 24, 2019.You asked the Plan to waive the copayment for the home visit. You say that you have a $0 copayment for home health.The Plan denied your request. The Plan says the copayment 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 $25 copayment per visit for urgently needed care.You have been asked to pay a $25 copayment for the home visit. The home visit falls within the "Urgently needed services" benefit category. The records show that this was an urgent home care visit. 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 home visit provided on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that the doctor you called won't see you because of
the virus. You say that you do not want to talk on a teleconference with someone you have never met. The Plan
denied your request. The Plan says there are in-network providers available for 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 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
an office visit to be provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received on August 23, 2018, and August 27, 2018.You asked thePlan to pay forthe services. You say that you want to be reimbursed.The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until January 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services you received on August 23, 2018, and August 27, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery, four or more contiguous teeth or tooth bounded spaces per quadrant (D4260 x 2), and the osseous surgery, 1 to 3 contiguous teeth or tooth bounded spaces per quadrant, (D4261 x 2) provided from June 20, 2019 to July 10, 2019.You asked the Plan to pay for the dental services. You say that you had periodontal surgery on June 20, 2019 and July 10, 2019. You say that the Evidence of Coverage (EOC) says periodontal planing, root scaling, and maintenance are covered services. You also say that the services should be covered for 25 to 30%. The Plan denied your request. The Plan says osseous surgery is not listed asa covered service.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 osseous surgery is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the osseous surgery, four or more contiguous teeth or tooth bounded spaces per quadrant (D4260 x2), and the osseous surgery, 1 to 3 contiguous teeth or tooth bounded spaces per quadrant, (D4261 x 2) provided from June 20, 2019 to July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on December 26, 2019.You asked the Plan to payforthe pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendorThe Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that your patient did not want to change primary care due to health insurance coverage. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 has network providers available who can provide 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 January 22, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided January 29, 2019 to January 30, 2019 and the acute inpatient hospital care provided from January 31, 2019 to February 2, 2019.You asked the Plan to pay for the laboratory services and the acute inpatient hospital care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services provided were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented on January 31, 2019 with complaint of altered mental status and severe headache. Symptoms persisted at the time of admission. The enrollee had diagnostic studies performed and received intravenous medication. A neurology consultation was obtained. Symptoms persisted on February 1, 2019 and evaluation and treatment continued. The enrollee had improved by February 2, 2019 and was discharged for outpatient follow-up. The record shows that at the time of inpatient admission, the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the laboratory services provided January 29, 2019 to January 30, 2019 and the acute inpatient hospital care provided from January 31, 2019 to February 2, 2019. 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-approve native coronary artery catheterization with left heart catheterization (93458).You asked the Plan to pre-approve native coronary artery catheterization with left heart catheterization. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 native coronary artery catheterization with left heart catheterization. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has some coronary risk but no documented angina, no documented acute ischemic electrocardiographic changes, no documented congestive heart failure and no documented ischemia on stress testing. In this circumstance the records do not support the medical necessity for cardiac catheterization. Coverage criteria are not met since the test is not appropriate for the enrollee's medical needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of native coronary artery catheterization with left heart catheterization have not been met.Therefore, we decided that the Plan does not have to pre-approvenative coronary artery catheterization with left heart catheterization (93458).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210) provided.
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, complete series of intraoral x-rays. You say that the dental provider gave you numerous excuses for why they would not pay for your standard exam. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered benefit. The Plan also says that the comprehensive oral evaluation and complete series of intraoral x-rays services exceed the frequency limitations in the benefit plan.
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 2D oral/facial photographic image is not among those covered under this benefit. The contract clearly states that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on January 24, 2019, and your comprehensive oral evaluation and complete series of intraoral x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210) provided.
Your complaint about your dissatisfaction with the Plan's dental coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (93976, 76700) provided December 11, 2019.You asked the Plan to pay for the Radiology services. You say that services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 93976 & 76700 are not supported in the medical record. Specifically, the claim is a duplicate of a previously paid claim. Based on this information, we decided that Medicare rules for coverage of the Radiology services have not been met.Therefore, we decided that the Plan does not have to pay for Radiology services (93976, 76700) provided December 11, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has severe persistent asthma. She has not tried and failed the Plan's required drug of Perforomist. The records do not support that the required drug would be contraindicated or less effective; therefore, Brovana is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Brovana.