Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the PPE, periodic oral evaluation, and prophylaxis provided on August 25, 2020.
You asked the Plan to pay for the PPE, periodic oral evaluation, and prophylaxis. You say that you received a document saying you may owe for these services. The Plan denied your request. The Plan says that you have exhausted your annual $500 dental benefit for the 2020 plan year.
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 contract states that the Plan offers a $500 combined coverage limit each year for comprehensive and preventive covered supplemental dental care services. The Plan did not provide any documentation showing when the annual $500 dental benefit was exhausted during the 2020 plan year. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the PPE, periodic oral evaluation, and prophylaxis provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/specialist visit.

You have been asked to pay a $35 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for the enrollee.

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 doctor's notes do not show enough information on what needs to be monitored by home health visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. As such, home health services are not shown to be medically necessary or reasonable. 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 home health visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. 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 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 were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two guided tissue regenerations (D4266 x2), bone replacement grafts for ridge preservation (D7953 x2), and inhalation of nitrous oxide/analgesia (D9230).

You asked the Plan to pay for the guided tissue regenerations, bone replacement grafts, and inhalation of nitrous oxide/analgesia. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services 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, 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 two guided tissue regenerations (D4266 x2), bone replacement grafts for ridge preservation (D7953 x2), and inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services.

You asked the Plan to pay for the services provided. You say that the lab work was ordered by your doctor at the bone clinic. The Plan denied your request. The Plan says that the service is not covered by your plan.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the services provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services.

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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 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 he 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.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been proven to be helpful.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found lateral sacral branch blocks and subsequent radiofrequency ablation are considered experimental/investigational because of the wide variation in efficacy reported in the literature. Therefore, the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up services provided on September 24, 2020.
You asked the Plan to pay for the core build up services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 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 pay for the core build up services provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
You asked the Plan to pre-approve TTE test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this TTE test is not medically necessary.
The Plan follows Medicare rules. Medicare rules state that TTE testing may be covered for evaluation of prosthetic heart valves under certain clinical conditions. 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 TTE test. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested TTE test. Our physician reviewer found the documentation provided indicates that this TTE is requested to evaluate the enrollee's replaced aortic valve. In this case, the enrollee has previously had a baseline examination. There is no documentation of suspected dysfunction, thrombosis, or a change in clinical status or symptoms. Therefore, the requested test 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 TTE test have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 21, 2020.

You asked the Plan to pay for hearing aids. You say that you were told that the Plan had a hearing benefit included this supplier. The Plan denied your request. The Plan says the denial of payment for these hearing aids is correct, because hearing aids are not covered unless they are obtained through the Plan's hearing aid vendor.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through the Plan's hearing aid vendor.

We looked at the file, Medicare rules, and the Plan's rules. These hearing aids were purchased from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided by an out-of-network provider.

You asked the Plan to pay for chiropractic services. You say that the manipulations were necessary to relieve pain. The Plan denied your request. The Plan says the provider was not a participating provider during the benefit period.

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 chiropractic services provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the emergency room visit (99282).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service is not payable as it was rendered by a non-certified Medicare provider.

The Plan must follow Medicare rules. Medicare rules say that Medicare institutional providers who are paid through a prospective payment system (PPS) must submit information to the Provider-Specific File (PSF).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. Specifically, the PSF file does show that the facility has submitted current information that is listed in the file, and the Centers for Medicare and Medicaid Services (CMS) letter submitted does show a recent certification; therefore, we can conclude that the CCN number indicated is valid. Additionally, the absence of spending data in the "Medicare Spending per Beneficiary - Hospital" database is not sufficient to determine that a CCN number is invalid given the other available information and the fact that the provider has not yet completed an entire fiscal year. Therefore, we decided that the Plan has to pay for the emergency room visit (99282).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units for radiology services (CPT 72040, CPT 72070, CPT 73020) provided to the enrollee.

You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your request. The Plan says the documentation supports one unit each of the denied codes.

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 the denied codes is:

CPT 72040:

Radiologic examination, spine, cervical

CPT 72070:

Radiologic examination, spine; thoracic, 2 views

CPT 73020:

Radiologic examination, shoulder; 1 view

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 additional units. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the records showed that the 2 view thoracic spine series and the cervical spine series were properly reimbursed. The provider's contention that 1 view bilateral shoulder series was not reimbursed is incorrect. There are two different dictations of the shoulders but there should have only been one. The billed and reimbursed bilateral shoulder series was correctly described and reimbursed. There is a redundant dictation of each shoulder, right and left separately which is recorded in the records as separate from the bilateral shoulder series, complete which was dictated separately. In summary the records support the reimbursement for bilateral shoulder series X1.

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 additional units have not been met. Therefore, we decided that the Plan does not have to pay for additional units for radiology services (CPT 72040, CPT 72070, CPT 73020) provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.

You asked the Plan to pre-approve Monovisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not covered.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs to remain in the facility. The Plan denied your request. The Plan says that the enrollee can be treated in a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically necessary and reasonable for the enrollee. The enrollee does not appear to require inpatient mental health treatment as she is not a danger to herself or others, has no auditory hallucinations or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place. It does not appear that the services are reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve Ondansetron. You say that the enrollee needs medication for post-op nausea and vomiting. The Plan denied your request. The Plan says Ondansetron to be taken at home is not covered under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.

Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.