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

We decided that the Plan does not have to waive the cost-sharing for the cleaning (D1110), periodic oral evaluation (D0120), and bitewing x-rays (D0274) provided on March 30, 2021, by an out-of-network provider.

You asked the Plan to waive the cost-sharing for the dental services. You say that you thought you were covered for dental services up to $1,000 per year, regardless of the network status of the provider. You thought you would just use up the benefit faster if you used an out-of-network provider and did not realize you would be responsible for the difference in cost. The Plan denied your request. The Plan says that they only pay up to a certain amount for services. If you receive care from an out-of-network provider, you may be billed for any amount that exceeds the maximum payment made by 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. Your contract with the Plan clearly says that there is a $0 copayment for periodic exams, dental cleanings, and bitewing x-rays. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the Plan pays, even for services listed as a $0 copayment. 

You have been asked to pay $144 for the dental services received from an out-of-network provider. The provider billed the Plan a total of $239 for the three services. The Plan's maximum allowed charge for these services totals $95. Because you are not responsible for a copayment for any of these services, the Plan has paid the full $95 allowed charge. An in-network provider would accept this amount as complete payment for these services, but out-of-network providers do not have this agreement with the Plan and are allowed to bill you the remaining amount ($239 - $95 = $144). 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-sharing for the cleaning (D1110), periodic oral evaluation (D0120), and bitewing x-rays (D0274) provided on March 30, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request.
The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that repeat thermal11 facet joint RFA at the same
anatomic site is considered medically reasonable and necessary provided the patient had a minimum of
consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the
ability to perform previously painful movements and ADLs as compared to baseline measurement using the
same scale.

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 RFA. Our reviewer says that the
services are medically necessary. Our physician reviewer found the enrollee has facet syndrome and had an
excellent response to therapy. In response to the change in the LCD, the request is considered medically
reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve
radiofrequency ablation (RFA).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for repair resin partial denture base, maxillary (D5612) provided May 18, 2021.

You asked the Plan to pay for the dental services. You say that you've had this impaired upper denture partial for a year and a half. It has been repaired 7 times. You've had to use all of your dental allowance because of these partials, and you've been without teeth for a long time. The Plan denied your request. The Plan says the annual maximum benefit allowance has been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan has an annual benefit of $2,100. The records show that you this benefit had been used on dates of service January 6, 2021 for $361.00, March 3, 2021 for $514.00 and April 19, 2021 for $1,225.00.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for repair resin partial denture base, maxillary (D5612) provided May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-contrast computed tomography of the heart with calcium scoring (CPT 75571).

You asked the Plan to pre-approve quantitative calcium scoring,. You say that given the factor of her age, she is reluctant to begin statin therapy and wants to understand your risks and potential benefits of medication therapy more precisely. Please reconsider the decision. The Plan denied your request. The Plan says quantitative calcium scoring is not a covered service and not medically necessary.

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. Based on this information, we decided that Medicare rules for coverage of quantitative calcium scoring, have not been met. Therefore, we decided that the Plan does not have to pre-approve non-contrast computed tomography of the heart with calcium scoring (CPT 75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee can no longer self-propel. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis.
The Plan follows Medicare rules. Medicare rules say that group 3 power wheelchairs are only covered under certain medical indications. 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 power wheelchair. Our physician reviewer found that the enrollee has a past medical history of diabetes, peripheral arterial disease and a lower extremity amputation who requires a wheelchair for mobility. There is no documentation that the enrollee has a diagnosis affecting his mobility indicated for coverage of the requested group 3 power wheelchair. The records indicate the enrollee's mobility limitation is due to his lower extremity amputation, peripheral arterial disease and diabetes and not due to a neurological condition, myopathy or a congenital skeletal deformity.
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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin.

You asked the Plan to pre-approve TheraSkin. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 TheraSkin. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that standard wound care has failed to improve the wound. Theraskin is not medically reasonable and necessary for this subacute surgical wound. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin have not been met. Therefore, we decided that the Plan does not have to pre-approve TheraSkin.
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 the enrollee is not able to participate in the rigors required for inpatient rehabilitation.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for congestive heart failure and pneumonia. Her medical problems are stable. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy telehealth services provided on January 18, 2021.

You asked the Plan to pay for psychotherapy (90837). You say that the services were medically necessary. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician.

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. The record does not show an attempt to consult with the enrollee's primary care physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy (90837) have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy telehealth services provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve knee surgery. You say that you are in a lot of pain and need surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-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 knee surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the records there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. You say that the requested provider is five minutes from your home, and you prefer to see this provider rather than driving or taking public transportation to an in-network provider. The Plan denied your request. The Plan says there are over 20 in-network physical therapists who can manage your condition and are accessible per Medicare rules. You have chronic back pain that can be managed by an in-network physical therapist.

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 and accessible who can provide the physical therapy services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided on January 29, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 services (S1015, S8301) provided on January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on November 16, 2020.

You asked the Plan to waive the copayment for laboratory tests. You say that the laboratory tests were part of your annual wellness exam and you should not owe a copayment. 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 a $10 copayment for laboratory tests. 

You received laboratory tests on November 16, 2020. Laboratory tests are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment.

You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 copayment for laboratory tests provided on November 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on February 15, 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 procedure code 77003 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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). 

We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 fluoroscopic guidance rendered on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair lift.

You asked the Plan to pre-approve a power wheelchair lift. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet nerve blocks.

You asked the Plan to pre-approve facet nerve blocks (64493, 64494, 64495). You say that the blocks were recommended by your pain management provider in lieu of pain medications. The Plan denied your request. The Plan says the request exceeds the frequency limitations.

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. The request is for bilateral injections at 3 levels which equals 6 injections. Based on this information, we decided that Medicare rules for coverage of facet nerve blocks (64493, 64494, 64495) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet nerve blocks.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any daily skilled nursing needs and does not require daily skilled therapy services in an inpatient facility. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.