Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveapplication of apligraph on the right foot (15275).You asked the Plan to pre-approveapplication of apligraph on the right foot (15275). You say that the requested application of apligraph on the right foot is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested apligraph on the right foot.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 application of apligraph on the right foot (15275). Our reviewer says that the enrollee does not meet criteria for the requested apligraph on the right foot. Our physician reviewer found after careful review of the enclosed information and the pertinent enclosed LCD guidelines for this case, the enrollee does not have a covered indication for the requested Apligraf of the right foot. It is well documented that this enrollee is suffering with ulcerations to the right foot, specifically lateral malleolus and lateral aspect of fifth metatarsal base. On 6/1/2020 the patient underwent OR debridement of the ulcerations. As of 7/13/2020 the ulcerations are still noted to bepresent. Unfortunately, the enrollee is also noted to be a poorly controlled diabetic, with the most recent hemoglobin A1c at 10.8. High levels of blood glucose can slow and/or inhibit healing regardless of what treatments you employ. It is well documented that this enrollee has already attempted conservative treatments including Santyl, alginate dressings, compressive wrappings with gauze and Kerlix as well as Ace bandage compression. Even after OR debridement, the enrollee continued to have a slowly healing ulceration. Another criterion that must be met prior to application of Apligraf is adequate vascular perfusion to the lower extremity. The medical documentation does not advise of an ABI or noninvasive vascular studies that would demonstrate that this enrollee has adequate perfusion to her lower extremity which would allow for healing. This criterion is necessary prior to authorization of any biological wound dressing. Therefore, because the enrollee is a poorly controlled diabetic with high blood glucose levels as well as unknown vascular status to the lower extremity, application of Apligraf cannot be considered 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 application of apligraph on the right foot (15275) have not been met.Therefore, we decided that the Plan does not have to pre-approveapplication of apligraph on the right foot (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 4, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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 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 review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrolleerequires 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on March 9, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of your health 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer is experimental for spine surgery. More research is needed.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 devicehave not been met.Therefore, we decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on March 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that prior authorization was not obtained as to not delay treatment. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained for these services.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 has network providers available who can provide 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 forskilled nursing services provided on March 17, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveparathyroid planar imaging for the enrollee.You asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysthe records do not show results of blood tests showing that levels are higher than normal.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 rulesto determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical necessity for parathyroid imaging hinges upon evidence of elevated parathormone and serum calcium levels. The notes describe an elevated parathormone level of greater than 5000 but there is no documented serum calcium level.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 imaging have not been met.Therefore, we decided that the Plandoes not haveto pre-approveparathyroid planar imaging for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for second opinion providedon January 31, 2020.You askedthe Plan to pay for the second opinion. The Plan denied your request. The Plan says the service is deemed routine, unauthorized 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 did not pre-approve the servicesat 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 second opinion provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy services provided by a participating provideron February 29, 2020.You asked the Plan to waive the copayment for immunotherapy services. You say that you were told there would be no copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules saya 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 $20 copayment for physician/practitioner services/specialist. You have been asked to pay $10.36 which is less than your copayment amount of $20 for immunotherapy services. The services that were provided were provided by a specialist; therefore, the correct copayment has been applied. Immunotherapy services fall within the physician/practitioner services/specialist 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 immunotherapy services provided by a participating provideron February 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99310) rendered by the out of network (OON) provider on February 18, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service wasprovided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service 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 this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care (99310) rendered by the out of network (OON) provider on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forMyocardial Perfusion Imaging (78452) provided March 12, 2020.You asked the Plan to waive the copayment forthe Myocardial Perfusion Imaging.You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was appliedThe 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 $225 copayment for Diagnostic Radiology. You have been asked to pay a $225 copayment for the Myocardial Perfusion Imaging. The Myocardial Perfusion Imagingfalls within the Diagnostic Radiology 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 forMyocardial Perfusion Imaging (78452) provided March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 15, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system (E2300).You asked the Plan to pre-approvethe power seat elevation system. You say that the powered seating system is medically necessary.The Plan denied your request. The Plan says this is not a covered item.The Plan must follow Medicare rules. Medicare rules say that powered seat elevation systems arenot a covered benefit. We looked at the file and Medicare rules. The requested feature is not a covered item. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe antigen therapy services received on February 21, 2020.You asked the Plan to waive the copayment forthe antigen therapy services. You say that you were advised that you would have no copayment for these services.The Plan denied your request. The Plan says the services were processed correctly per your plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit to a specialist. You have been asked to pay a $20 copayment for the antigen therapy services. The antigen therapy services fall within the physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 forthe antigen therapy services received on February 21, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous process spacer device.You asked the Plan to pre-approveinsertion of an interspinousprocess spacer device. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 an interspinous process spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed.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 an interspinous process spacer device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous process spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraspinal chiropractic manipulative treatment (98943) provided on March 5, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under yourcontractual policy.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. However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. Though the Plan offers a chiropractic benefit in excess of Medicare coverage, the service provided isnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe extraspinal chiropractic manipulative treatment (98943) provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, bitewings, and crown provided from February 20, 2020 to March 5, 2020.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, bitewings, and crown. You say that you believe the services should be covered because you understood the Plan to be separate from Medicare. You also say that if the handbook regarding non-covered providers had been clearer, you would have gone to a different dentist.The Plan denied your request. The Plan says this provider opted out of Medicare on March 23, 2016. The Plan also says that they are unable to make payment for services provided by a dentist 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 practitionerwho 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. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, bitewings, and crown provided from February 20, 2020to March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter. 
 
You asked the Plan to pre-approve an oximeter. You say that because of your medical condition it will be easier to check your oxygen level with an oximeter. The Plan denied your request. The Plan says an oximeter is not necessary for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover oximeters. Based on this information, we decided that Medicare rules for coverage of an oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve an oximeter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillary partial denture provided on February 20, 2020 by an OON provider.You asked the Plan to pay forthe maxillary partial denture. You say that you contacted the Plan to see if this provider was accepted by your plan and were told yes. You also say that you were told your denture benefit was 30%.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that services performed by an OON provider are notcovered because your plan does not have OON benefits.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, you are responsible for 100% of the cost for partial dentures received from an OON provider. The Plan confirmed that there are no call records of a provider verification from you prior to the services being rendered.Therefore, we decided that the Plan does not have to pay forthe maxillary partial denture provided on February 20, 2020 by an OON provider.