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

We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance provided on January 27, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you would like these services to be covered, because you do not want to find a new provider. The Plan denied your request. The Plan says the services were rendered by a provider who is not under contract with the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance provided on January 27, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on January 11, 2021.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (90837) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. 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 primary care physician.
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 physician services provided on June 29, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is
experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee has low back pain with neurogenic claudication. The case file
indicates that magnetic resonance imaging (MRI) scans demonstrate severe spinal stenosis. The elements of the
coverage rule are not satisfied.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process device procedure.
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee needs this device to relieve lumbar pain. The Plan denied your request. The Plan says there are not enough studies to show that use of the device is better than regular spine surgery for the enrollee's problem.
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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Interlaminar spacer devices remain experimental. More research is needed to show safety and efficacy of the devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar/interspinous process device procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 28, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says the services were rendered by a provider who is not under contract with the health plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 28, 2021 by an OON provider.
Your complaint about your disappointment in the Plan for requiring you receive services from in-network providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns you received for teeth #8 and #9 on August 6, 2020.
You asked the Plan to pay for the crowns. The Plan denied your request. The Plan says the crowns are not medically necessary.
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 crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the requested crowns for teeth #8 and #9 are not medically reasonable and necessary in this case. Our physician reviewer found that the documentation provided did not meet the criteria for coverage for crowns (D2740) for teeth #8 and 9. There did not appear to be significant coronal breakdown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Please note that provider has agreed to write off the core buildup services (D2950), therefore you have no financial responsibility for these services. Therefore, we decided that the Plan does not have to pay for the crowns you received for teeth #8 and #9 on August 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 24, 2020.
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 procedure code 20610 is not supported.
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 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. We find that CPT code 20610 is not supported in the medical record. Specifically, the records show that injection of platelet rich plasma was performed and there is a more appropriate code for these services. 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 pay for the surgical services rendered on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a compression pump.

You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says the records need to show that the ulcers failed to heal after six months of conservative therapy.

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 pump. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the compression pump appear to exceed your medical need. The specifics of the type of pump requested is not clear. There is no evidence of venous stasis disease. There is no evidence of lymphedema on an objective physical examination. There is no evidence of failure of a trial of regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression, or failure of regular exercise and leg elevation. In the setting of venous insufficiency, there should be failure also of appropriate wound care and medications as appropriate.

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 pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a compression pump.
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 the clinical documentation provided supports the need for care in an LTACH. The Plan denied your request. The Plan says the records do not show the enrollee is medically stable to leave the acute care hospital. The Plan says that the enrollee needs to stay in the hospital until he is better.

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 to the hospital due to heart disease. He has had a lengthy hospital stay complicated by heart bypass surgery and a stroke, requiring brain surgery. He had severe breathing problems and required a breathing machine and attempts to wean from the machine have been unsuccessful. The most recent medical records demonstrate that his mental condition is severely impaired, and he is not responding to verbal or touch stimuli or following commands. The documentation indicates that there is no indication for 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 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit provided on September 30, 2020 by an
OON provider.
You asked the Plan to pay for the physician visit. You say that there was not time to properly request
authorization due to the health risk to the enrollee. The Plan denied your request. The Plan says the service was
rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.
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 physician visit provided on September 30, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a total knee arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient hospital care is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested acute inpatient hospital care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for acute inpatient hospital care are met in this case. Our physician reviewer found that an inpatient stay is not needed for total knee surgery. The procedure may be safely performed with a 48-hour observational stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care related to a total knee arthroplasty.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, basic life support, emergency transport
(A0429, A0425) provided on July 27, 2020.
You asked the Plan to pay for the ambulance service, basic life support, emergency transport (A0429, A0425). The Plan denied your request. The Plan says that the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service, basic life support, emergency transport (A0429, A0425). Our reviewer says that the ambulance services were medically necessary. Our physician reviewer found that given the consideration of possible COVID-19 in this enrollee, as stated in the medical records, it would be medically appropriate to transport him via ambulance to the hospital for further evaluation. The medical records indicate some distress with ongoing abdominal symptoms that would need to be further addressed within a healthcare setting by a physician in order to discern the extent of severity. 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 ambulance service, basic life support, emergency transport (A0429, A0425) have been met. Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on July 27, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on August 4, 2020.
You asked the Plan to pay for the occupational therapy. The Plan denied your request. The Plan says we have
insufficient documentation to corroborate the services so we cannot confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to
justify payment of the claim. Therefore, we decided that the Plan does not have to pay for occupational therapy
provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block injection (64454).
You asked the Plan to pre-approve a genicular nerve block injection. You say that this request is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the requested service is helpful for the enrollee's medical condition.
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 a genicular nerve block injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered an experimental and investigational procedure and is the subject of ongoing clinical trials. 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 a genicular nerve block injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block injection (64454).