Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation, intravenous antibiotics, peritoneal dialysis, surveillance laboratory studies, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate partial mandibular denture (D5222).
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says immediate dentures are not a covered service.
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, an immediate partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an immediate partial mandibular denture (D5222).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not meet criteria for starting Retacrit. The enrollee's hemoglobin level is over 10 and hematocrit level is over 30, and iron stores are low as noted by low iron saturation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (99204) with an out of network provider provided on July 10, 2019 and waive the copayment for specialist services (99204) provided on October 1, 2019.You asked the Plan to pay for the out of network visit and waive the copayment for the specialist services. You say that you would like reconsideration as you were told you could see an out of network provider and had 30 days to obtain authorization. The Plan denied your request. The Plan says you self-referred to an out of network provider and your cost share for the specialist visit 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 $50 copayment for specialist services. You have been asked to pay a $50 copayment for the specialist services. The specialist services fall within the Physician/Practitioner services, including doctor's office visits 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 specialist services (99204) provided on October 1, 2019. The rules say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. 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 services. Therefore, we decided that the Plan does not have to pay for the out of network office visit provided on July 10, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean immediate maxillary denture (D5130).You asked the Plan to pre-approvethe immediate maxillary denture. You say that a new upper denture is required for the enrollee. You say that the 3 remaining teeth need to be extracted due to gross caries.ThePlan denied your request. The Plan says the frequency limit for an immediate maxillary denture had been reached. The Plan says that 1 immediate maxillary denture per 60  months is covered.Medicare generally does not cover dental services. However, thePlan 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 immediate dentures are a covered service, the frequencylimit of once per 60 months has been reached. The record shows that the Plan previously paid for an upper denture that the enrollee received on February 23, 2016.Therefore, we decided that the Plan does not have to pre-approvean immediate maxillary denture (D5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010) for tooth # 23 and 26.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says implants are not a covered service.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 excessof Medicare coverage, the requested implants are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe surgical placement of an implant body (D6010) for tooth # 23 and 26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no medical issues that require supervision by an inpatient rehab physician three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee's current level of function is minimal assist for lower body dressing, and ambulation with moderate assist using a wide-based quad cane. 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 documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional speech, physical, and occupational therapy, but she is making gains in the skilled nursing facility and does not require this therapy on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast reconstruction for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says that the clinical information is not sufficient to support the medical necessity of this procedure.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 41 year old female with a history of left breast cancer and plans for bilateral mastectomy and bilateral breast reconstruction with tissue expanders. This is consistent with standard breast reconstruction and should be considered medically necessary. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. As the patient has a history of left breast cancer and plans for bilateral mastectomy, breast reconstruction is necessary as part of standard procedure. This satisfies Medicare medically necessary criteria. There is sufficient clinical information to support the procedures.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pre-approve breast reconstruction for the enrollee.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services from the requested physician. You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider.The Plan denied your request. The Plan says the requested provider is not in network.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 out of network physician services requested physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 97032) provided to the enrollee on May 25, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. We looked at the file and Medicare rules. Per L35456, the requested electrical stimulation is considered not medically reasonable and necessary for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases.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 forthe services (CPT 97032) provided to the enrollee on May 25, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 16, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits, vitamin B12 injection and diagnostic tests provided from January 8, 2019 through July 9, 2019.
You asked the Plan to waive the cost share for the office visits, vitamin B12 injection and diagnostic tests. You say that you were not informed you owed for any services. The Plan denied your request. The Plan says the cost share 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 $10 copayment for services obtained from a primary care provider, 20% coinsurance for each Medicare-covered Part B drug and 20% coinsurance for Medicare-covered non-radiological diagnostic services.
You have been asked to pay a total of $99.77 for the office visits, vitamin B12 injection and diagnostic tests.
Date of Service
Service
Allowed Amount
Standard Cost
Member Liability
January 8, 2019
Office Visit
110.83
$10
$10
January 8, 2019
Vitamin B12 Injection
$1.96
20%
$0.39
January 31, 2019
Office Visit
110.28
$10
$10
February 20, 2019
Office Visit
110.28
$10
$10
February 20, 2019
Duplex Scan
$198.94
20%
$39.79
May 7, 2019
Office Visit
$75.32
$10
$10
July 9, 2019
Office Visit
$75.32
$10
$10
July 9, 2019
Psychological Test
$47.93
$9.59
TOTAL:
$99.77
The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The vitamin B12 injection falls within the "Medicare Part B Prescription Drugs" benefit category. The duplex scan and psychological test fall within the "Outpatient Diagnostic Tests and Therapeutic 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 cost share for the office visits, vitamin B12 injection and diagnostic tests provided from January 8, 2019 through July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exome sequence analysis (CPT 81415) and Whole mitochondrial genome sequencing (CPT 81460).
You asked the Plan to pre-approve the exome sequence analysis and the whole mitochondrial genome sequencing services. You say that the requested testing is urgently needed so that the enrollee does not get worse. The appellant says that the notes provided support the need for the requested testing. The Plan denied your request. The Plan says neither Medicare or the enrollee's Medicare Advantage Plan covers the services in dispute.
The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when it is considered medically necessary for certain indications. We looked at the file and Medicare rules. The type of genetic testing being requested is statutorily excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve exome sequence analysis (CPT 81415) and Whole mitochondrial genome sequencing (CPT 81460).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ambulatory surgical shoe (L3260) to be provided by provider.You asked the Plan to pre-approve the surgical shoe. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says an ambulatory surgical shoe is not a covered benefit under your contractual policy.The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. Shoes are also covered if they are an integral part of a covered leg brace.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested surgical shoe have not been met.Specifically, the records show that you do not have diabetes and do not have a leg brace that is an integral part of a shoe. Additionally, orthopedic footwear billed as code L3260 will be denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve an ambulatory surgical shoe (L3260).
Appeal type: Lab
Decision: Unfavorable

We decided that thePlan does not have to pay for drug testing services provided to the enrollee on June 5, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 fordrug testing services provided to the enrollee on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvean epidural steroid injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has had three of the same injections in the current six month period.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the enrollee underwent lumbar spine injections on 10/9/19, 10/16/19,1/16/20 and 1/25/20. This exceeds the limit as outlined in the guidelines. Medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visits provided on August 28, 2019 and September 25, 2019.You asked the Plan to waive the copayment forthe office visits. You say that these were follow up visits. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayments 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 $50 copayment for each Medicare-covered specialist visit. You have been asked to pay $39.50, which is less than the standard $50 copayment for the office on August 28, 2019. You have also been asked to pay a $50 copayment for the office visit on September 25, 2019. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 forthe office visits provided on August 28, 2019 and September 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for PT services provided on January 28, 2019.
You asked the Plan to pay for the PT services. You say that the services should be paid. The Plan denied your request. The Plan says that following multiple requests for medical records, there is insufficient documentation to corroborate the services.
The Plan must follow Medicare rules. Medicare rules say that treatment notes or a treatment log must be submitted for all disciplines describing all skilled interventions and all treatments provided to the beneficiary. We looked at the file and Medicare rules. In this instance, the documentation did not include a daily timed treatment note for the date of service at issue, complete with time spent for each code billed. Based on this information, we decided that Medicare rules for coverage of the PT services have not been met. Therefore, we decided that the Plan does not have to pay for PT services provided on January 28, 2019.