Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient behavioral health visit provided on September 24, 2019.
You asked the Plan to waive the copayment for the outpatient behavioral health visit. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for outpatient mental health care. You have been asked to pay a $40 copayment for the outpatient behavioral health visit. The outpatient behavioral health visit falls within the "Outpatient mental health care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient behavioral health visit provided on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (C9752 and 22899).You asked the Plan to pre-approve the Intracept Procedure. You say that this procedure is FDA approved and beneficial. The Plan denied your request. The Plan says this service is 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 pre-approve the Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental for the treatment of back pain and more research is needed to show its safety and efficacy.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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (C9752 and 22899).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical assistant services provided to the enrollee on August 7, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this type of provider is not eligible for payment for assistant surgeon services.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to payforthe surgical assistant services provided to the enrollee on August 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart transplant at your requested facility.
You asked the Plan to pre-approve a heart transplant at your requested facility. You say that it would be dangerous for you to travel outside of Puerto Rico for your heart transplant. The Plan denied your request. The Plan says heart transplants must be done at a Medicare-approved facility.
The Plan must follow Medicare rules. Medicare rules say that cardiac transplantation is covered under Medicare when performed in a facility which is approved by Medicare as meeting institutional coverage criteria. We looked at the file and Medicare rules. The facility you have requested has not approved by Medicare as meeting institutional coverage criteria. Based on this information, we decided that Medicare rules for coverage of a heart transplant at your requested facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a heart transplant at your requested facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental service. You say that your wisdom tooth is infected. You say that there is an abscess and it is causing you pain. You also say that you need to have this done by an oral surgeon because you are Prolia injections and it could cause complications with your jaw.The Plan denied your request. The Plan says dental services performed by an oral surgeon are not covered. The Plan also says that in order for dental services to be covered, they must be performed by a participating general dentist.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 coverageand extractions are a covered service, dental servicesperformed by an oral surgeonare not covered.Dental services must be provided by a participating general dentist in order to be covered.Therefore, we decided that the Plan does not have to pre-approvea surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe second transport provided on October 28, 2019.You asked the Plan to pay forthe ambulance transport, claim #021366552900. You say that there were two transports on the same day as shown by the Patient Care Reports.The Plan denied your request. The Plan says that this claim is a duplicate.The Planmust follow Medicare rules. Medicare rules say that claims must be submitted with the appropriate medical record information. The rules also state health plans must make diligent efforts to forward in formation to the IRE. The records clearly show that the enrollee had two separate transport serviceson the same day at different times of the day. The health plan did not present a clear argument for denial. Based on the medical records provided, Medicare coverage criteria for the payment of this claim are met. Therefore, we decided that the Plan has topay forthe second transport provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no medical reason documented that the enrollee is medically unable to use the preferred meters.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are OneTouch Ultra Verio test strips. OneTouch Ultra is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approveOneTouch Verio test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for after-hour care (99053) provided on November 17, 2019.
You asked the Plan to pay for the after-hour care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is part of the primary procedure and will not be reimbursed.
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 find that CPT code 99053 is not supported in the record. Specifically, per Medicare, CPT code 99053 has a status indicator of B. This means that CPT code 99053 is a bundled code and has been designated as always included in another service. Based on this information, we decided that Medicare rules for coverage of the after-hour care have not been met. Therefore, we decided that the Plan does not have to pay for after-hour care (99053) provided on November 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the enrollee is likely to require 3-4 more weeks of acute care which is best provided in an LTACH which specializes in care for these patients.The Plandenied your request. The Plansaysan LTACH is not able to specialize in any sort of care that can be considered superior to the care provided in any other short-term 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. Our physicianreviewer found the patient is currently undergoing treatment at an ACH for a sacral wound with osteomyelitis. The enrollee has undergone wound debridement and is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stairway lift/elevator.You asked the Plan to pre-approvethe requested item. You say that you are unable to go down the steps forward because your knees give out.The Plan denied your request. The Plan says the item does not serve a primarily medical purpose.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 thisappeal 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-approvea stairway lift/elevator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95999, A4556, A4557) provided on March 27, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are bundled services.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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure".We find that CPT code 95999 is not supported in the medical record. Specifically, train of four testing is not an unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four testing, along with codes A4556 and A4557, are bundled services and are not separately payable from the primary procedure. 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 services (95999, A4556, A4557) provided on March 27, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2751) and the core build up (D2950) for teeth# 8 and 9 provided on October 14, 2019.You asked the Plan to pay for the dental services. You say that you cannot afford the payment for these services. You also say that if the payment is late, they will charge too much interest.The Plan denied your request. The Plan says that this type of treatment is only covered when it is done because the tooth has decay. The Plan also says that no documentation, x-rays or photographs were provided to justify these services.The Plan must follow Medicare rules. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The rules say that the Plan must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan is basing its denial on not receiving the x-rays to support that this was reasonable and necessary;however,records/x-rays of a contract provider are considered to be within the control of the plan and should have been submitted in the original case file in order to support the denial on this basis. Without these records, we cannot confirm that the Plan's denial is supported. Since this was provided by a network dentist with no prior notice of non-coverage, we find that this service is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the crown (D2751) and the core build up (D2950) for teeth # 8 and 9 provided on October 14, 2019.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 30, 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 on October 30, 2019.
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 necessary.The Plan denied your request. The Plan says based on the documentation provided, 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, you do not meet criteria for coverage for an admission to an IRF. You were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current medical stability.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from September 9, 2019 to September 10, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with appropriate G and Q codes. We looked at the file and Medicare rules. The home health claims were not billed with the required G and Q codes. 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 home health services rendered to the enrollee from September 9, 2019 to September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 31, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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
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 laboratory services provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Candy Apple Red Shroud (K0108).
You asked the Plan to pre-approve a Candy Apple Red Shroud. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a Candy Apple Red Shroud does not serve a medical purpose and is not covered.
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 Candy Apple Red Shroud (K0108).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Diagnostic digital breast tomosynthesis (77062) provided August 15, 2019 by provider You asked the Plan to pay forthe Diagnostic digital breast tomosynthesis. You say that the services were medically necessary.The Plandenied your request. The Plan says rules for coverage were not met.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 find that CPT code 77062 is not supported in the medical record. Specifically, according to the 2019 Year National Physician Fee Schedule Relative Value File July Release, code 77062 is not valid for Medicare billing. Based on this information, we decided that Medicare rules for coverage of the Diagnostic digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fora Diagnostic digital breast tomosynthesis (77062) provided August 15, 2019 by provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that orthotics are medically necessary in balancing and redistributing weight on the member's foot structure. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that oral bisphosphonates are an option due to GERD. The Plan denied your request. The Plan says the enrollee has not tried an oral bisphosphonate and zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has a diagnosis of Wedge compression fracture of the first and second lumbar vertebrae, subsequent encounter for fracture with routine healing. It is noted that the enrollee has GERD without esophagitis. The Plan requires a trial of an oral bisphosphonate drug and Zoledronic acid before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. While an oral bisphosphonate may not be appropriate for this enrollee, the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.