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

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the enrollee's plan allows for coverage with an in-network provider only. Exceptions are made for urgent and emergent care. There are in-network providers available to provide these services to the member.

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 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 physician's services to be provided by the requested out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on July 31,
2020.
You asked the Plan to pay for the hospital discharge day management. You say that the treating provider
rendered medically necessary services to the enrollee in good faith. 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. 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 the hospital discharge day management provided on July 31,
2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computerized tomography (CT) scan.

You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the
documentation supports that the requested services are medically reasonable and necessary. Our physician
reviewer found you have a higher pre-test probability for pulmonary embolism given the prior known history
of deep vein thrombosis. You are also no longer being treated for this with anticoagulation. Your symptoms
were atypical for angina pectoris, but their intermittent and pleuritic nature associated with palpitations were
possibly consistent with pulmonary embolism. As your d-dimer was also elevated, based on the prior history
and higher pre-test probability, the symptoms, and the laboratory findings (d-dimer elevation), CT scanning to
rule out pulmonary embolism is medically necessary. Therefore, you meet criteria for the requested 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 a CT scan have been met. Therefore, we decided that the Plan has to pre-approve
a computerized tomography (CT) scan.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the LinQ joint stabilization system rendered on September 1,
2020.
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 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 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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee had left sacroiliac (SI) joint
instability and severe chronic sacroiliitis. The LinQ system is experimental for SI joint fusion, as more research
is needed to show safety and efficacy. The services were therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the LinQ joint stabilization system rendered on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist hand finger orthosis (L3809) provided on December 14, 2020.

You asked the Plan to pay for a wrist hand finger orthosis. You say that this should be covered. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual only regarding the furnishing of such covered item, or another covered item to this same individual within 15 months.

We looked at the file and Medicare rules. the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. The submitted documentation is not sufficient to show that the enrollee gave written permission to make contact by telephone regarding the furnishing of a covered item. As such, no payment may be made for this item. Based on this information, we decided that Medicare rules for coverage of a wrist hand finger orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a wrist hand finger orthosis (L3809) provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 13,
2020.
You asked the Plan to waive the copayment for the office visit. You say that you were scheduled to have a
colonoscopy on this date. You say that it was not done until November, but the claim was doubled. The Plan
denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for each specialist in-person office visit.
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show a
specialist visit was billed for this date of service. 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 office visit provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs provided on September 22, 2020, and November 9, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree with the increase in charges. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received a Medicare Part B drug on September 22, 2020. The total allowed amount is $276.80 and 20% of that is $55.36. 

You received a Medicare Part B drug on November 9, 2020. The total allowed amount is $1,916 and 20% of that is $383.20. 

The total amount you owe is: $438.56.

You have been asked to pay the total coinsurance amount of $438.56 for Medicare Part B prescription drugs. Medicare Part B prescription drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B prescription drugs provided on September 22, 2020, and November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered on January 15, 2020.
You asked the Plan to waive the deductible for these services. You say that you had the same procedure twice and do not understand the difference in cost sharing. The Plan denied your request. The Plan says the deductible was applied 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 $1,000 yearly deductible for your covered medical services and a $400 copayment after you pay your $1,000 deductible for each in-network Medicare-covered outpatient surgery at an outpatient hospital. Review of the file shows that you received outpatient surgical services at an outpatient hospital facility on January 15, 2020. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 15, 2020. The Plan applied a total of $195.76 to your deductible for these services. At this time, the $1,000 yearly deductible had been met.
Given that the deductible did not cover the entire cost of the services, you have also been asked to pay a $400 copayment for these services after meeting the $1,000 deductible. The total amount you have been asked to pay for these services is $595.76. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered on January 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 member can remain in the current acute care location until
such time no further acute level care is needed.
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
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. 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 LTACH services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the iontophoresis provided on November 17, 2020.

You asked the Plan to pay for the iontophoresis. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis that has not been responsive to recognized standard 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 pay for the iontophoresis. Our reviewer says that the requested iontophoresis is not medically reasonable and necessary in this case. Our physician reviewer found that the LCD criteria have not been met as the documentation does not reveal that iontophoresis was being used for a diagnosis of hyperhidrosis, but rather for left shoulder pain. 

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 iontophoresis have not been met. Therefore, we decided that the Plan does not have to pay for the iontophoresis provided on November 17, 2020.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar laminectomy and fusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq
cm or less wound surface area (15275) and application of skin substitute graft to face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each
additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary
procedure) (15276). We decided that the Plan does not have to pay for surgical preparation or creation of
recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional
release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple
digits; first 100 sq cm or 1% of body area of infants and children (15004).
You asked the Plan to pay for surgical preparation or creation of recipient site by excision of open wounds,
burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body
area of infants and children (15004), application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq
cm or less wound surface area (15275) and application of skin substitute graft to face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each
additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary
procedure) (15276). You say that the Plan should pay this claim. The Plan says that the service codes are not
substantiated by the clinical documentation in the medical records submitted.
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 the surgical procedures. Our reviewer says
that the records support the application of skin substitute procedures only. Our reviewer found in this case, the
documentation does not indicate that the provider prepared or created the site. The site was previously prepared
by the amputation billed by another surgeon. Therefore, CPT code 15004 cannot be recommended. The
operative note indicates that PuraPly, a skin substitute was applied to an area of 54 cm2 on the right foot. The
elements of 15275 and 15276 are satisfied. CPT code 15275 and 15276 are recommended.
We decided that the Plan has to pay for application of skin substitute (15275, 15276).
We also decided that the Plan does not have to pay for surgical preparation (15004).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the adjunctive procedure (abutment supported porcelain/ceramic crown) provided on December 7, 2020.
You asked the Plan to pay more for the abutment supported crown. You say that you would like this service to be covered. The Plan denied your request. The Plan says the $1,000 annual allowance has been paid to you by the Plan. The Plan also says that any further payment for the dental services will not be issued because you have already received the full amount of the dental allowance for Non-Medicare covered dental services for the 2020 plan year.
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 Plan offers a $1,000 dental allowance every year for Non-Medicare covered preventive dental services and Non-Medicare covered comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the December 7, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the adjunctive procedure (abutment supported porcelain/ceramic crown) provided on December 7, 2020.