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

We decided that the Plan does not have to pre-approve an office visit (99204, 99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you performed a procedure on the member while she was in inpatient hospital care on February 12, 2020. You also say the member needs a follow-up visit with you. The Plan denied your request. The Plan says there are in-network providers available 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 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 an office visit (99204, 99214) 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 the inpatient psychiatric hospitalization.

You asked the Plan to pre-approve the inpatient psychiatric hospitalization. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time for the dates in question as they did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient did not show any abnormal behaviors or any symptoms which would require acute 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 inpatient psychiatric hospitalization have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization.
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 information provided supports the enrollee's need for acute rehabilitation. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 8, 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 the services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
Guardant360 panel rendered on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positive airway pressure (PAP).
You asked the Plan to pre-approve positive airway pressure (PAP). You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that PAP is only covered for certain 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 positive airway pressure (PAP).. Our
reviewer says that the documentation does not support that the requested device is medically reasonable or
necessary. Our physician reviewer found the enrollee has a diagnosis of obstructive sleep apnea. There is no
documentation that the enrollee meets criteria for the Positive Airway Pressure (PAP) device as records do not
document consistent use of the Positive Airway Pressure (PAP) device for an average of four hours or more per
24 hours for at least 70 percent of nights. The most recent records report 30% compliance using the device at
least 4 hours per night for the period June 30, 2021 to July 29, 2021. Therefore, the enrollee does not meet
criteria for the requested device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of positive airway pressure (PAP). have not been met. Therefore, we decided that
the Plan does not have to pre-approve positive airway pressure (PAP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on April 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit securement package (K0108) for a wheelchair.
You asked the Plan to pre-approve the package. You say that this is medically necessary. The Plan denied your request. The Plan says this item is for use in transportation, and not for home use.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit securement package (K0108) for a wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260), a wheelchair seat cushion (E2622) and a pressure pad for a mattress (E0185) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a semi-electric hospital bed, a wheelchair seat cushion and a pressure pad for a mattress. You say that you are requesting reconsideration for the durable medical equipment as the member has out-of-network benefits and would like to use those benefits. The Plan denied your request. The Plan says there are in-network providers available 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 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 a semi-electric hospital bed (E0260), a wheelchair seat cushion (E2622) and a pressure pad for a mattress (E0185) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) for teeth # 4, 5, and 21.

You asked the Plan to pre-approve the dental services. You say that you are missing teeth on the right top half of your mouth and lower bottom left. You say that it is difficult to chew food. You also say that you were previously told that this provider was in network only to find out they are not. The Plan denied your request. The Plan says custom fabricated abutments 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 custom fabricated abutments are not among those covered under this benefit, regardless of the provider's network status.

Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) for teeth # 4, 5, and 21.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection of amniotic fluid (Flow Fluid).

You asked the Plan to pre-approve the Flow Fluid injection services. You say that the requested therapy is appropriate for the enrollee. You say that the other approaches used to treat the enrollee's condition have only provided temporary relief and improvement. You say that Fluid Flow is the only medication that has the power to regenerate the tissue injury with few side effects. The Plan denied your request. The Plan says there are not enough studies to show that use of Fluid Flow is better than regular treatment of shoulder pain or will help with your care.

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 Flow Fluid injection services. Our reviewer says that the Flow Fluid injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found this solution is not approved by the Food and Drug Administration (FDA). There have been warnings published regarding the use of stem cells. 

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 Flow Fluid injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection of amniotic fluid (Flow Fluid).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 11, 2021.
You asked the Plan to pay for the services provided. You say that the receptionist assured you they were in-network. The Plan denied your request. The Plan says there is no coverage when services are rendered by an out-of-network provider.
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 file shows that dental services were received by an out-of-network provider. We looked at the file, and Medicare rules. Your plan only covers services when provided in-network. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99255) provided on October 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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. Code 99255 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is 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 (99255) provided on October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided to the enrollee on December 7, 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 these codes are invalid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that the denied codes are not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 to the enrollee on December 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) (78812) scan
provided on April 5, 2021.
You asked the Plan to pay for a PET scan. You say that this was billed correctly. The Plan denied your request.
The Plan says this was not billed with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate
diagnosis code.
We looked at the file and Medicare rules. The billed diagnosis code, C45.9, is not listed as an appropriate code.
Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) (78812)
scan provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prescription lenses for your sunglasses (V2219).

You asked the Plan to pre-approve prescription sunglass lenses. You say that you have not used the frames portion of your benefit in several years and would like the Plan to cover sunglass lenses instead. The Plan denied your request. The Plan says sunglass lenses are not covered by your supplemental vision benefits. You also previously had eyeglass lenses provided in June of 2021, and therefore you have met your benefit limitation for the next two years.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of eyeglass lenses every two calendar years. 

We looked at the file and the Plan's rules. Documentation shows that you previously had lenses provided in June of 2021. Based on this information, we decided that the Plan's rules for coverage of prescription lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve prescription lenses for your sunglasses (V2219).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 24, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on October 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation (G0378), an
emergency department visit (99285), emergency ambulance services (A0427SH), and a radiological
examination of the chest (71045) provided on March 11, 2021.

You asked the Plan to waive the copayment for hospital observation, an emergency department visit,
emergency ambulance services, and a radiological examination of the chest. You say that you should not have
to pay these charges. The Plan denied your request. The Plan says the claims processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible.

The items or services you asked the Plan to waive the copayment for falls within the benefit categories
ambulance services, and outpatient hospital services. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible that must be met before the Plan will pay their share
for covered medical services. You met your deductible and therefore are only responsible for the diagnostic
imaging which applied $8.88 towards the deductible, the ambulance services which applied $361 towards the
deductible and since the deductible was satisfied the remaining $70.46 applied as a copayment and the hospital
observation which applied a $125 copayment Therefore, we decided that the Plan does not have to waive the
copayment for hospital observation (G0378), an emergency department visit (99285), emergency ambulance
services (A0427SH), and a radiological examination of the chest (71045) provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided April 5, 2021.

You asked the Plan to pre-approve foot orthotics. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673).

You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says these items are not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provided treatment for PAD is not eligible for reimbursement. In addition, the PCD related accessories are not eligible for reimbursement if the base PCD is not covered.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is excluded from Medicare coverage. Since the base is not eligible for coverage, the accessories are also not covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673).