Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 and does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a LTACH is not medically
necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal assistance services (S5215) for 29 hours per week.

You asked the Plan to pre-approve personal assistance services. You say that there was a miscommunication between you and your case manager. The Plan denied your request. The Plan says the requested services are custodial in nature. The Plan also says that custodial care is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal assistance services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal assistance services (S5215) for 29 hours per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management services provided on April 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the prolonged evaluation and management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 prolonged evaluation and management services provided on April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on May 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the x-ray. You say that you would like the authorization approved and the claim reprocessed. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the x-ray provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound scan of veins of both arms or legs (93970) provided on January 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the ultrasound scan of veins of both arms or legs. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not received for these services rendered by an OON provider.
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 ultrasound scan of veins of both arms or legs (93970) provided on January 4, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 14, 2021.

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 payment is included in the global surgical package.

The Plan must follow Medicare rules. The rules say that post-surgical management is included in the global
surgical package.

We looked at the file and Medicare rules. The services at issue are post-surgical management billed with code
33223 (relocation of skin pocket for implantable defibrillator). These services were performed within and
related to the global surgical period for major surgical procedure 33249 (insertion or replacement of permanent
implantable defibrillator system, with transvenous lead(s), single or dual chamber). Payment for these services
is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the
surgical services rendered on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that a dentist has referred you to an oral surgeon for these services. You also say that you feel that these services should be covered under your plan. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist. The Plan also says that dental services to be performed by an oral surgeon 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 services are not among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) to be provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 23, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels with suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation. We find that the hereditary screening is not supported in the medical record. Specifically, there is insufficient records to show that the ordered testing is diagnostic, or clearly correlates any test result with given interventions. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower and shower equipment.

You asked the Plan to pre-approve a walk-in shower or shower equipment of any kind. You say that a walk-in shower or shower equipment is required for safety. The Plan denied your request. The Plan says walk-in showers and/or shower equipment is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower equipment is not covered because it is not primarily medical in nature. While a walk-in shower or shower equipment may be appropriate for you to use, neither the Plan nor Medicare offers coverage of this type of equipment. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower and shower equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided from November 25, 2020, to February 12, 2021.
You asked the Plan to pay for the services provided. You say that the attached records support your claim. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided from November 25, 2020, to February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft (D4263) for teeth # 3, 14, 18, and 30.
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says bone replacement grafts are not listed as covered services.
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 bone replacement grafts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft (D4263) for teeth # 3, 14, 18, and 30.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) abdomen (74183).
You asked the Plan to pre-approve the MRI. You say that the enrollee did have a CT done and it did show you what she has but the CT is not clear enough for you to do surgery or concerning for renal cell carcinoma. You need a dedicated renal MRI before surgery. The Plan denied your request. The Plan says the records show that the same study or test like it has already been done. Repeat imaging is not supported without results of prior imaging that show a clear reason for it.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found repeat imaging is not supported without results of prior imaging that show a clear reason for it. The CT provides sufficient information to allow the clinician to proceed with treatment.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) abdomen (74183).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services (66984) provided to the enrollee on November 2, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 66984 79 LT (1 unit) remains 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 66984 is "extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation." 

We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records.

Our reviewer found after a careful review of the documentation, there was nothing found to support the services performed on November 2, 2020. The submitted is for dates of service November 3, 2020 and November 9, 2020. Therefore, the services are unable to be verified, and therefore, not covered. 

We looked at this coder'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 pay for ophthalmology services (66984) provided to the enrollee on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and external heart monitoring to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON office visits and external heart monitoring. You say that the requested services are needed in order for you to get clearance for surgery. The Plan denied your request. The Plan says there is no medical need shown as to why the services cannot be gotten through a plan network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits and external heart monitoring to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection of substance into middle or upper spine canal using imaging guidance (62321) provided September 14, 2020, to September 30, 2020.
You asked the Plan to waive the copayment for the injection of substance into middle or upper spine canal using imaging guidance. You say that you believe you have been improperly charged for these services. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $340 copayment for outpatient hospital services. You have been asked to pay a $340 copayment for the injection of substance into middle or upper spine canal using imaging guidance. This service falls within the outpatient hospital services benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection of substance into middle or upper spine canal using imaging guidance (62321) provided September 14, 2020, to September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics provided on October 8, 2020.

You asked the Plan to pay for the services provided. You say that prior approval was obtained. The Plan denied your request. The Plan says the service denied correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and the rules. The records do not show that the services were billed with an appropriate modifier. 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 pay for the orthotics provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on February 10, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on
January 14, 2021.

You asked the Plan to pay for CTC assay. You say that this is a unique, proprietary test which is an accepted
standard of care. The Plan denied your request. The Plan says this testing is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that CTC assay tests are not covered by Medicare for
date of service January 14, 2021.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of CTC assay have not been met. Therefore, we decided that the Plan does not have to pay for
circulating tumor cell (CTC) assay testing provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic shoes and inserts provided on July 15, 2020.

You asked the Plan to waive the coinsurance for diabetic shoes and inserts. You say that your diabetic shoes and inserts should be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for diabetic therapeutic shoes or inserts. You received diabetic shoes and inserts on July 15, 2020. The total allowed amount is $295.67 and 20% of that is $59.13. 

You have been asked to pay the total coinsurance amount of $59.13 for diabetic shoes and inserts. Diabetic shoes and inserts fall within the diabetes self-management training, diabetic services and supplies 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 coinsurance for diabetic shoes and inserts provided on July 15, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for MTHFR genetic testing provided on June 23, 2020.

You asked the Plan to pay for MTHFR testing. You say that this test is covered by Medicare and you are appealing with supporting records. The Plan denied your request. The Plan says that this testing is not covered by Medicare.

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. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that MTHFR testing would not be covered. This testing is not excluded from Medicare coverage for the date of service and geographic location of service. Under Medicare rules, this means MTHFR testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for MTHFR genetic testing provided on June 23, 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 Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network outpatient mental healthcare.

You asked the Plan to pre-approve continued care with an out of network provider. You say that you prefer to continue to see the requested provider. The Plan denied your request. The Plan says you have not exhausted the providers available in-network that can provide this treatment.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees must use network providers for routine care. The Plan has several network providers available who can provide outpatient mental health care and outpatient mental health therapy. We found no exception that would require the Plan to pre-approve these services out-of-network. Therefore, we decided that the Plan does not have to pre-approve out-of-network outpatient mental healthcare.