Persius/hicric huggingface dataset:
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

You asked the Plan to pre-approve an MRI of the lumbar spine. 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. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found there has been no neurological evaluation documented in the chart to indicate any red flag which would mandate MRI without first attempting a 6-week trial of physical therapy and follow-up visit to assess success or failure of such a program prior to MRI. The administration of injected steroids does not constitute the conservative management required for medical necessity of MR imaging in the absence of red flag.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (tildrakizumab) injections.

You asked the Plan to pre-approve the Ilumya. You say that the enrollee has had psoriasis for many years and was forced to stop taking Cosentyx due to insurance issues. The Plan denied your request. The Plan says there is no evidence that the enrollee has tried the preferred drugs.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The rules also require providers to submit sufficient information to support that coverage criteria are met. 

There are no medical records submitted by the ordering provider, despite requests. There is no evidence that the enrollee has used Ilumya in the past 12 months. A form filled out by the treating provider states that the enrollee has not tried any of the preferred drugs, such as Inflectra or Stelara. There is nothing noting an intolerance to any of these drugs. Therefore, we decided that the Plan does not have to pre-approve Ilumya (tildrakizumab) injections.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit with current procedural terminology (CPT) code 99285.

You asked the Plan to pay for CPT code 99285. You say that the medical records support the billing of CPT code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 99285.

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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

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 CPT code 99285. Our reviewer says that the medical records do not support the billing of CPT code 99285. Our physician reviewer found the enrollee received services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiological diagnostic tests provided on October 8, 2020.
You asked the Plan to waive the copayment for the radiological diagnostic tests. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received three different radiological diagnostic tests on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $85 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received three different radiological diagnostic tests on October 8, 2020. You have been asked to pay a $85 copayment for each radiological diagnostic test, totaling $255. The radiological diagnostic tests fall within the Outpatient diagnostic tests 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 radiological diagnostic tests provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert system.

You asked the Plan to pre-approve an alert system. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is non-covered.

The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an alert system have not been met. Therefore, we decided that the Plan does not have to pre-approve an alert system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services and the inpatient mental health care provided on August 15, 2020.

You asked the Plan to waive the copayments for the ambulance services and the inpatient mental health care. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received ambulance services and inpatient mental health care on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

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 $240 copayment for Ambulance services and $1,763 per stay for Inpatient mental health care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance services on August 15, 2020. You have been asked to pay a $240 copayment for the ambulance services. The ambulance services fall within the Ambulance services benefit category. The file also shows that you received inpatient mental health care on August 15, 2020. You have been asked to pay a $1,763 copayment for the inpatient mental health care. The inpatient mental health care falls within the Inpatient mental health care benefit category. This means that you have been asked to pay the correct amounts 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 the ambulance services and the inpatient mental health care provided on August 15, 2020.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 3, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 physician services provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 skilled nursing visits, 6 aide visits, and 2 social worker visits.

You asked the Plan to pre-approve 4 skilled nursing visits, 6 aide visits, and 2 social worker visits. 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 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 4 skilled nursing visits, 6 aide visits, and 2 social worker visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Therefore, the provision of home health service is not 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 4 skilled nursing visits, 6 aide visits, and 2 social worker visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 skilled nursing visits, 6 aide visits, and 2 social worker visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass dental crowns for teeth #'s 19 and 30.

You asked the Plan to pre-approve the dental crowns. You say that it is felt these crowns are necessary. The Plan denied your request. The Plan says crowns are not part of the enrollee's dental coverage.

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 white glass dental crowns for teeth #'s 19 and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 2 surgical extractions (D7210) provided on December 1, 2020.

You asked the Plan to pay for the dental services. You say that the services were denied due to the benefit being exhausted. You say that you do not agree with this. You also say that you enrolled in the supplemental dental plan. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan says there is a $1,000 annual maximum for covered dental services. The Plan also says that annual maximum has been exhausted.

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 and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on February 28, 2019. Additionally, the $1,000 annual maximum has been exhausted.

Date of Service
Plan Paid
1/22/2020
$471
1/30/2020
$366
3/4/2020
$130
6/3/2020
$33
TOTAL:
$1,000

The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 2 surgical extractions (D7210) provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial exam provided on November 24, 2020.

You asked the Plan to pay for the initial comprehensive preventive medicine evaluation and management exam. You say that you changed doctors and needed the exam. The Plan denied your request. The Plan says you had a wellness exam on February 6, 2020.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the initial exam provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 covered chiropractic services with current procedural terminology (CPT) code 98941 at issue in this appeal. The Plan did not pre-approve the chiropractic services at issue. We found no exception that would require the Plan to pay for these items/services. Furthermore, the only covered chiropractic services are manual manipulation of the spine to correct subluxation. CPT codes 99203 and 97110 are not manual manipulation of the spine and are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 laboratory services provided by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the nuclear stress test rendered.

You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied correctly.

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 there is $245 yearly deductible for in-network medical services and 10% of the cost for each in-network Medicare-covered diagnostic radiology and complex imaging service after any deductible.

Review of the file shows that you had a nuclear stress test. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $245 yearly deductible for in-network medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received. The Plan applied a total of $114.30 towards your deductible. At this time, the in-network deductible had been met.

Given that the deductible did not cover the entire charge for these services, you have also been asked to pay 10% of the cost of the remaining Medicare-allowed amount, for a total of $110.38. The total amount you have been asked to pay for these services is $224.68. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan.

Therefore, we decided that the Plan does not have to waive the cost sharing for the nuclear stress test rendered.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on June 1, 2020.

You asked the Plan to waive the copayment for these services. You say that the copayment is against the law. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment per day for ultrasounds.

Review of the file shows that you had a breast ultrasound on June 1, 2020. You have been asked to pay a $60 copayment for these services. These services fall within the ultrasounds 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. The Plan has not denied coverage for these services. The Plan paid their portion and the amount you are being asked to pay is your contractual copayment. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered on June 1, 2020.