Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a muscle or tendon transfer (24301) provided on January 28,
2021.
You asked the Plan to pay for a muscle or tendon transfer. You say that this code is supported in the operative
note. The Plan denied your request. The Plan says this code is not documented.
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 24301 is muscle or tendon transfer, any type, upper arm
or elbow, single (excluding 24320-24331).
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 muscle or tendon transfer. Our reviewer
says that this code is not supported. Our physician reviewer found the operative report does not include enough
documentation to support a muscle transfer was performed, instead describing a bicep tenodesis.
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 muscle or tendon transfer have not been met. Therefore, we decided that the
Plan does not have to pay for a muscle or tendon transfer (24301) provided on January 28, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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 oral exam (D0120), prophylaxis (D1110), and the complete series x-ray (D0210) provided on January 26, 2021.
You asked the Plan to pay for the dental services. You say that you had out of network benefits in 2020. You say that you have been seeing this dentist for 30 years. You say that you did not change plans. You also say that you do not understand why your plan was changed from out of network to in network without your knowledge. The Plan denied your request. The Plan says the policy you had in 2020 and 2021 are exactly the same and do not include out of network coverage. The Plan says that you did not have out of network benefits in 2020. The Plan also says that dental services performed out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the complete series x-ray (D0210) provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 mild to moderate left
knee osteoarthritis. The records do not show that he has tried and failed the Plan's required drugs, Orthovisc
and Monovisc or that the required drugs would be contraindicated or less effective. The Synvisc-One 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 Synvisc-One.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dialysis provided from January 3, 2021,
through January 29, 2021.

You asked the Plan to waive the copayment for the dialysis. You say that you did not have to pay for your
dialysis in previous years and were not aware that your cost-share would change to be 20%. The Plan denied
your request. The Plan says the claims were processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received dialysis from January 3, 2021, through January 29, 2021. You were
asked to pay 20% coinsurance for the dialysis. Your 2021 EOC states enrollees must pay 20% coinsurance for
outpatient dialysis.

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 dialysis provided from January 3, 2021, through January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy 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 by a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provenge.
You asked the Plan to pre-approve Provenge. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Provenge. Our reviewer says that the medication is not medically necessary. Our physician reviewer found as the enrollee is still on lupron he would not be considered castrate resistant. The enrollee also has no evidence of progression and his prostate-specific antigen (PSA) was o.798 on March 17, 2021. The service is 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 Provenge have not been met. Therefore, we decided that the Plan does not have to pre-approve Provenge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on March 29, 2021.
You asked the Plan to pay for the limited evaluation. You say that this exam was necessary to understand and treat your dental problems. The Plan denied your request. The Plan says the Plan only covers routine (periodic) and comprehensive oral evaluations. Limited evaluations are not covered by your dental benefit.
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 limited (problem-focused) oral evaluation (D0140) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the enrollee was in a nursing home setting at the time services were rendered. The enrollee could not choose an in-network neurologist since no other provider was allowed into the facility during the Covid 19 pandemic. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 subsequent nursing facility care (99308) provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for myocardial perfusion tomographic imaging (78452) performed on July 27, 2020.
You asked the Plan to waive the coinsurance for myocardial perfusion tomographic imaging. You say that you paid a $75 copayment to the provider on August 6, 2020, for surgery and believe that the myocardial perfusion tomographic imaging you received should be included in the surgery copayment. 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.
You have been asked to pay $75 for myocardial perfusion tomographic imaging. Myocardial perfusion tomographic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for myocardial perfusion tomographic imaging (78452) performed on July 27, 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 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 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 medically necessary. Our physician reviewer found you are living at home with increased back pain and weakness. You have no complex nursing or rehabilitation needs. The records do not show that you require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. You may benefit from physical and occupational therapy but do not require an intensive therapy program in an IRF. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory test provided by an out-of-network provider on February 17, 2021.
You asked the Plan to pay for the office visit and laboratory test. You say that the provider is the patient's primary care physician and authorization is not needed for this visit. You say that the services should be reviewed and deemed payable. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 and laboratory test provided by an out-of-network provider on February 17, 2021.
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 the enrollee was admitted with respiratory failure and atrial fibrillation with rapid ventricular response. The enrollee continues to require high flow oxygen and has evidence of multiple pulmonary emboli. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory drug testing services (80307, 80299, 82542, 83789, G0482) rendered by the out of network (OON) provider on October 7, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory drug testing services (80307, 80299, 82542, 83789, G0482) rendered by the out of network (OON) provider on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received May 6, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee should not owe any money because the enrollee has reached the 2020 out-of-pocket maximum. The Plan denied your request. The Plan says at the time the claim was processed for this date of service, the enrollee had only applied $3,447.01 toward the $5,500 out-of-pocket maximum.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee must pay a $250 copayment for Ambulance Services. The Plan has submitted evidence that the enrollee had not yet reached the $5,500 out-of-pocket maximum at
the time the ambulance transportation claim was processed. The enrollee has been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous drug administration services provided on February 4, 2021 billed with code 96401.
You asked the Plan to pay for the subcutaneous drug administration services. You say that this was billed correctly. The Plan denied your request. The Plan says there is a more appropriate code to report this 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. In this case, the CPT Code Manual definition of code 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.
We asked our coding 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 subcutaneous drug administration services. Our reviewer says that the reported code for this drug's administration is not appropriate. Our coding reviewer found use of the chemotherapy administration code is not supported. Per billing guidelines, code 96372 would be used. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subcutaneous drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the subcutaneous drug administration services  provided on February 4, 2021 billed with code 96401.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230), and the intraoral - periapical first radiographic image (D0220) received January 18, 2021.
You asked the Plan to pay for the intraoral radiographic images. You say that these images were taken to check the status of a tooth after an incomplete procedure. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 intraoral - periapical each additional radiographic image (D0230), and the intraoral - periapical first radiographic image (D0220) received January 18, 2021.