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

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that the requested scan is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria for the requested service have not been met.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that in this case the enrollee does not have a tobacco smoking history of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastroenterology office visit, tertiary level.
You asked the Plan to pre-approve a gastroenterology office visit, tertiary level. You say that you are more comfortable getting care you need with this doctor. The Plan denied your request. The Plan says an office visit at a tertiary level is not medically necessary.
Medicare rules say that plans can require enrollees to get care from network providers. The Plan policy states tertiary level service is medically necessary when care is needed that the Plan doctors are not able to provide.
The requested provider in this case is not on the Plan's Care Team. The Plan has providers available who can provide the services at issue in this appeal. The referring doctor did not provide supporting information as to why the enrollee should have care with the requested doctor. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a gastroenterology office visit, tertiary level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99213) provided on March 10, 2021, through March 12, 2021.
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you were referred for these services by your primary care physician and were not informed of the providers intent to perform other services. The Plan denied your request. The Plan says only manual manipulation to correct subluxation is covered.
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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits (99213) provided on March 10, 2021, through March 12, 2021.
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
bitewing x-rays (D0274) provided on October 20, 2020.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that
payment cannot be made for dental services performed by a provider that has opted out of Medicare.
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. The Plan covers the dental
services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the provider in this case has opted out of
Medicare. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis
(D1110), and the bitewing x-rays (D0274) provided on October 20, 2020.
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 you need LTACH care. The Plan denied your request. The Plan says the records do not show that you have a complex illness requiring LTACH care or the special nursing care at the LTACH level is needed.
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 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 she is 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on August 11, 2020.
You asked the Plan to pay for the x-ray 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 a duplicate claim to a previously processed and paid claim.
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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, this x-ray service is a duplicate to a claim previously processed and paid by the Plan. This means this service is a duplicate and cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the x-ray
services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services
provided on August 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan and an X-ray provided from February 3, 2021, to February 4, 2021.

You asked the Plan to waive the copayments for a CT scan and an X-ray. You say that you disagree with the charges because the services were to treat your severe anemia. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $175 copayment for advanced imaging services and a $100 copayment for basic radiological services. 

You received a CT scan and an X-ray from February 3, 2021, to February 4, 2021. Therefore, you are responsible to pay a $175 copayment for the CT scan and a $100 copayment for the X-ray. The total amount you owe is: $275. 

You have been asked to pay the total copayment amount of $275 for a CT scan and an X-ray. A CT scan and an X-ray fall within the outpatient hospital 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 copayments for a CT scan and an X-ray provided from February 3, 2021, to February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from February 2, 2021, to February 7, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware that you would owe a copayment and have never been charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $298 copayment for days 1-7 for inpatient hospital care. 

You had an inpatient hospital stay from February 2, 2021, to February 7, 2021. Therefore, you are responsible to pay a $298 copayment for days 1-5 (February 2, 2021, to February 6, 2021). The total amount you owe is:

$298 (copayment) x 5 (inpatient days) = $1,490. 

You have been asked to pay the total copayment amount of $1,490 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from February 2, 2021, to February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s) (A5500) and multiple density insert, direct formed, molded to foot (A5512), provided on October 16, 2020, through October 27, 2020.
You asked the Plan to pay for a diabetic shoe for density insert and a multiple density insert. You say that the item is medically necessary. The Plan denied your request. The Plan says DME must be purchased through a Medicare participating vendor.
The Plan must follow Medicare rules. Medicare rules say that DME must be purchased through Medicare participating vendors.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that the provider at issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s) (A5500) and multiple density insert, direct formed, molded to foot (A5512), provided on October 16, 2020, through October 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been 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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 72-year-old female with a history of osteoporosis. In this case, the Plan requires a trial of Zoledronic Acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis and resin-based composite provided on September 16, 2020 and November 18, 2020.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis and resin-based composite. You submitted your bills for review. The Plan denied your request. The Plan says payment cannot be issue to a provider that has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis and resin-based composite provided on September 16, 2020 and November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and massage therapy to be provided by a massage therapist.

You asked the Plan to pre-approve office visits and massage therapy. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says services provided by a massage therapist are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve office visits and massage therapy to be provided by a massage therapist.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and arthrocentesis provided on January 12, 2021
You asked the Plan to pay for the office visit and the arthrocentesis. You say that the enrollee was seen for the
administration of medication in the hip. You would like the authorization approved and the claim reprocessed.
The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not confirm if the 2021 Evidence of Coverage sent with the case
file was correct. This means we are unable to determine if the lock-in rules are correct. Therefore, we decided
that the Plan has to pay for the office visit and arthrocentesis provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D1208, D4355).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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 pre-approve dental services (D1208, D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and the addition to lower extremity orthosis provided on October 17, 2020.

You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. 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 payable.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain proof of delivery for the supplies provided in this case. The documentation does not include an itemized shipping/billing invoice to indicate the specific supplies rendered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis and the addition to lower extremity orthosis provided on October 17, 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.
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 that you do 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 provided in a lower level of care. This means admission into an IRF is not medically necessary. 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 29, 2021 with concern for sepsis. She does not require services at the LTACH that are not available at the acute care hospital where she is 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.

You asked the Plan to pre-approve Methotrexate. You say that the enrollee has severe erosive progressive rheumatoid arthritis that is currently being under-treated due to lack of access to proper medications. You say that Methotrexate is the first line of treatment for rheumatoid arthritis. The appellant says that the enrollee needs to resume Methotrexate as soon as possible to prevent further damage. The Plan denied your request. The Plan says they were unable to reach the doctor in order to complete the coverage review process.

The Plan must follow Medicare rules. Medicare rules say that to consider coverage for any item or service, the provider must supply medical documentation in order to confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The case file shows that the Plan made reasonable attempts to obtain medical records. However, no medical records were provided. Without this clinical documentation we are unable to determine whether the medical necessity criteria have been met. Based on this information, we decided that Medicare rules for coverage of Methotrexate have not been met. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the head or brain (70450) performed on July 25, 2019.
You asked the Plan to pay for a CT scan of the head or brain. You say that the provider performed the services in question and should be paid accordingly. The Plan denied your request. The Plan says rules for payment have not been met because the claim was submitted after the timely filing period.
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 a CT scan of the head or brain was not filed until April 14, 2021. 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 for a CT scan of the head or brain (70450) performed on July 25, 2019.