Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy.
You asked the Plan to pre-approve physical therapy. 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 must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that the services are medically necessary. Our physician reviewer found the records support that the unique skills of a professional therapist are required to safely and effectively provide treatment for you in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have been met. Therefore, we decided that the Plan has to pre-approve physical therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on September 28, 2020.
You asked the Plan to pay for the psychotherapy. You say that the service was provided without adequate time to obtain authorization. You say that the records reflect the medical necessity for the services and the claim should be reprocessed for payment. The Plan denied your request. The Plan says utilization of in-network providers is required unless the Plan pre-approves out-of-network services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided by an out-of-network provider on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve a partial lower denture. You say that the item is necessary. The Plan denied your request. The Plan says the benefit 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 covers 1 complete or partial denture every 5 years. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial lower denture have not been met. Specifically, you received a denture on February 14, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain/ceramic crowns (D6058 x2), and pontic (D6245) provided on September 29, 2020.
You asked the Plan to pay for the custom fabricated abutments, abutment supported crowns, and pontic. You say that you believe these services should be covered because they were provided due to a medical issue. The Plan denied your request. The Plan says the custom fabricated abutments and abutment supported crowns are not covered benefits under your dental plan. The Plan also says that your annual maximum benefit had been met.
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 custom fabricated abutments and abutment supported crowns are not among those covered under this benefit. The contract also says that the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the September 29, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain/ceramic crowns (D6058 x2), and pontic (D6245) provided on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87507) provided October 12, 2020.
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says the procedure was not billed with the correct CPT code.
The Plan must follow Medicare rules. Medicare rules say that to report a CGP, service providers should use CPT code 81479. We looked at the file and Medicare rules. The genetic testing was performed and was not billed using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87507) provided October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminotomy (63030 and 63035), laminectomy (63047
and 63048) and the transpedicular approach with decompression of spinal cord (63056 and 63057).
You asked the Plan to pre-approve the laminotomy, laminectomy and transpedicular approach with
decompression. You say that you would like reconsideration because this procedure is urgent, and the member
is in extreme pain. The Plan denied your request. The Plan says the CPT coding is incorrect for the service that
is being requested.
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 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 pre-approve the laminotomy, laminectomy and transpedicular
approach with decompression. Our reviewer says that the provider is requesting a decompression be performed
at the L4/L5 level, and if needed, the L3/L4 level. CPT 63030 laminotomy (hemilaminectomy), with
decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated
intervertebral disk; one interspace, lumbar, would be the appropriate code to report for this procedure, and CPT
63035 laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy,
foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar,
would be appropriate if L3/L4 level is performed. Our reviewer found the remainder of the requested CPT
codes, would be inappropriate to report for services requested.
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 laminotomy, laminectomy and transpedicular approach with decompression
have not been met. Therefore, we decided that the Plan does not have to pre-approve a laminotomy (63030 and
63035), laminectomy (63047 and 63048) and the transpedicular approach with decompression of spinal cord
(63056 and 63057).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 13, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the treatment rendered to the enrollee was medically necessary. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not 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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 13, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care hospital.
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. The enrollee was readmitted for an ileus after aortobifemoral bypass surgery. The enrollee currently has an infected groin graft, has a drain in place and is receiving acute care services that have not been denied. The enrollee does not require services that he is not currently receiving that only the LTACH could provide. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on September 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 psychotherapy services (90832) provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88313) provided on October 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that these services were provided in good faith. The Plan denied your request. The Plan says these services were not authorized.
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 laboratory services (88305, 88313) provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BRCA genetic testing provided on October 19, 2020.
You asked the Plan to pay for BRCA testing. You say that you have family members which had breast cancer and feel you were wronged by not being allowed to have this testing approved. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare if you have no personal history of cancer or signs/symptoms of cancer.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is not covered for genetic screening in the general population and for testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. We looked at the file and Medicare rules. You did not have any signs/symptoms or personal history of a cancer for which this testing may be covered. Based on this information, we decided that Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pay for BRCA genetic testing provided on October 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on October 14, 2019.
You asked the Plan to pay for the chest x-ray. You say that the enrollee was not under hospice care on this date
of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of
all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on October 10, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray
provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing provided on September 30, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is experimental/investigational.
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 pay for genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Caris MI biomarker analysis assesses DNA, RNA, and proteins. The documentation does not support that comprehensive tumor profiling is medically reasonable and necessary and will impact the management and outcome of the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for testing provided on September 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray provided on December 31, 2020.
You asked the Plan to pay for the hip x-ray. You say that the enrollee's hospice coverage ended on December 2, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hip x-ray provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 services provided by an out-of-network provider on December 17, 2020.
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.
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 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 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. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on June 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. 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 genetic testing provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on December 2, 2020.
You asked the Plan to pay for the dental service. You say that you feel that the provider made an error in the
code that was provided on the claim. You say that per your Evidence of Coverage, service code D0150 covers a
comprehensive exam for a new patient. You say that is what you were led to believe was performed. You also
say that you notified the provider explicitly not to perform a service that was not covered. The Plan denied your
request. The Plan says comprehensive periodontal evaluation is not listed as 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, 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 the
comprehensive periodontal evaluation (D0180) provided on December 2, 2020.
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. You say that the enrollee needs LTACH services. The
Plan denied your request. The Plan says the services needed may be done in an acute hospital setting.
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 patient does not require services at the LTACH that are not already available at
the current facility. There are no services at the LTACH that the patient requires that are not already available
and covered at the current facility. Therefore, this request for LTACH services will be considered not
medically necessary at this time. Transfer may be considered when treatment has completed and long-term
needs are more clearly 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.