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

We decided that the Plan does not have to pre-approve the medical services to be performed by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services are not emergent or urgent and are available within your network. The Plan states to please be advised that although the medical group has already authorized you to see a network orthopedic provider, it was agreed that the medical group will authorize a second opinion with another in-network orthopedic provider who treats shoulder conditions.
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. As the year has changed since the appeal began, please check your 2021 EOC for coverage rules regarding your out-of-network benefits. Therefore, we decided that the Plan does not have to pre-approve the medical services to be performed by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be had at an alternate level of care.
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 currently undergoing treatment at an ACH for an esophageal perforation
and CoViD-19. The enrollee was initially intubated/ventilated for surgery and subsequently received a
tracheotomy. The enrollee is tolerating ventilator weaning. There is no evidence that the enrollee requires
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level
of care for any ongoing long term care 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the abdominal and chest x-rays provided
on July 9, 2020.
You asked the Plan to pay for the x-ray interpretations. You say that these services were provided in an
appropriate place of service. The Plan denied your request. The Plan says the enrollee was inpatient at the time
these services were rendered. As such, the POS code 22 is not correct.
The Plan must follow Medicare rules. Medicare rules say that for registered inpatients, providers must report
POS code 21.
In this case, the Plan provided documentation showing that the enrollee was a registered inpatient from July 5,
2020, to July 25, 2020. As such, POS code 21 would be appropriate. Therefore, we decided that the Plan does
not have to pay for the interpretation of the abdominal and chest x-rays provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided thatthe Plan has to pay forthe eye exam received on September 22, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe eye exam. You say that you were told that this provider was in network.The Plan denied your request. ThePlan says that the services received are not a covered benefit when provided by an OON provider.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay 30% of the cost for oneroutine eye exam every year. The Plan says you must pay for the eye exam. You are being charged the total amount of $50 for the eye exam. Based on the Plan contract, however, you cannot be asked to pay more than 30% coinsurance for the eye exam.30% of the total amount of $50 would be $15. The plan cannot charge you more than the $15 coinsurance for these services. Therefore, we decided that the Plan has to pay forthe eye exam received on September 22, 2020, by an out-of-network (OON) provider.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: 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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. You are currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. You 
are not intubated/ventilated. There is no evidence that you require services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to 
the LTACH. You can remain at the current ACH until such time no acute services are required. You can then 
be transferred/discharged to a lower level of care for any ongoing long-term care 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 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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 31, 2020, to 
September 10, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the care provided was medically 
necessary. The Plan denied your request. The Plan says that the inpatient care provided was not medically 
necessary and a lower level of care would have been appropriate. 
 
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 review indicates that the enrollee presented to the ER on August 31, 2020, with shortness of 
breath. On evaluation her vital signs were stable, and the physical exam was remarkable for a prolonged 
respiratory phase. She was treated with supplemental oxygen, IV steroids and nebulizer treatments. She was 
admitted and continued dialysis. Her condition stabilized and improved, and she was discharged home on 
September 10, 2020, when considered medically stable. The review has determined that the record showed 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 acute inpatient hospital care provided from August 31, 2020, to September 10, 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-approve dorsal root ganglion pulsed radiofrequency ablation
(RFA) (CPT Code 64999).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are considered experimental and 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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found pulsed RFA of the RFA is considered experimental/ investigation for the treatment of lumbar
radicular pain. Therefore, the request is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve dorsal root ganglion pulsed radiofrequency ablation (RFA) (CPT Code 64999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement
graft for ridge preservation (D7953), and consultation (D9310) provided from August 10, 2020, to August 14,
2020.
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft, and consultation. You say
that these services were necessary in order for you to have the ability to chew your food. The Plan denied your
request. The Plan says these services are not covered under your 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 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
guided tissue regeneration (D4266), bone replacement graft for ridge preservation (D7953), and consultation
(D9310) provided from August 10, 2020, to August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not include a physician order, lab requisition, or medical records stating exactly which tests 
were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis provided on August 13, 2020. 
 
You asked the Plan to pay for the ankle orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had an ankle orthosis at the time the ankle orthosis was received. The 
enrollees current ankle orthosis previously received on November 7, 2019 serves the same purpose as the 
ankle orthosis provided on August 13, 2020. The documentation does not support why a replacement was 
needed before the five year reasonable lifetime period was up. Therefore, we decided that the Plan does not 
have to pay for the ankle orthosis provided on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the respirator rental provided from January 26,
2019, to December 26, 2019.
You asked the Plan to waive the charges for the respirator rental. You say that you were never made aware that
your respirator was being rented. You feel that prior to switching plans, you should have been informed that
you would need to pay monthly rental payments for this equipment you had. You believe that these charges
should be waived because you were not made aware that they would be incurred. The Plan denied your request.
The Plan says you have been renting this equipment, and the plan has correctly applied the 20% coinsurance to
these charges.
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%
coinsurance for durable medical equipment and related supplies.
You have been asked to pay 20% coinsurance for the respirator rental. The respirator rental falls within the
durable medical equipment and related 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
charges for the respirator rental provided from January 26, 2019, to December 26, 2019.
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. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they 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 the diagnosis and condition of the 
enrollee and 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injections provided from June
12, 2020, to September 14, 2020.
You asked the Plan to waive the coinsurance for the Botox injections. You say that your income is limited and
it is very difficult to continue paying for the injections. You say you have never before had to pay a copayment
for the required Botox injections. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
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% of
the Medicare-allowed amount when administered in an office/clinic.
You have been asked to pay 20% of the allowed amount for the Botox injections on each date of service. The
allowed amount is $613. ($613 x 20% = $122.60). The Botox injections fall within the "Medicare Part B
prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for the Botox injections provided from June 12, 2020, to
September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services received on September 17, 2020.
You asked the Plan to pay for the services. You say that you weren't aware that refraction was not covered. The
Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction.
The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does
not have to pay for refraction services received on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of Spinal Stenosis have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer is experimental. More research is needed to show safety and efficacy. Hardware is not needed in this case where there is no spinal instability documented. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 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 a Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuing medical physics consultation services provided on August 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the continuing medical physics consultation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
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 continuing medical physics consultation services provided on August 13, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vitoss Allograft services.
You asked the Plan to pre-approve Vitoss Allograft. 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. 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 Vitoss Allograft. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Vitoss allograft remains experimental for use in cervical spine surgery. More research is needed
to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vitoss Allograft have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vitoss Allograft services.