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

We decided that the Plan does not have to pay foran office visit (99214) provided on August 6, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that the physiciam, is in-network with all the plan's providers. You say this keeps happening that credentialing says she is a participating provider but the claims department says their computer says that she is not.The Plan denied your request. The Plan says the services were not authorized becausethe physician is a non-network provider who does not work with the member's health plan and the member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 has network providers available who can provide the items/services atissue 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 foran office visit (99214) provided on August 6, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaboratory and x-ray services provided while out-of-area.You asked the Plan to pre-approvethe out-of-area laboratory and x-ray services. You say that your doctor intended for you to undergo lab work-up and x-ray to find out etiology of your anemia. You say that the clinical documentation provided supports the need for these services.The Plan denied your request. The Plan says the guidelines for coverage of services outside of the service area have not been met.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. We found that the need for the services being requested was known of before the enrollee left the service area. We found that the services in dispute were not unforeseen and, therefore, are not considered urgent/emergent out-of-area care. Based on this information, we decided that Medicare rules for coverage of the out-of-area laboratory and x-ray services have not been met.Therefore, we decided that the Plan does not have to pre-approvelaboratory and x-ray services provided while out-of-area.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve2 crowns (D2740) for teeth # 6 and 7, and 3 core build up (D2950) for teeth # 6, 7, and 15 to be provided.You asked the Plan to pre-approvethe dental services. You say that you cannot afford to pay for these services on your own. You say that one of these teeth already has a crown, but it is cracked and needs to be replaced.The Plandenied your request. The Plan says that the requested services are not covered.The rules say a health plan must disclose to its enrollees in clear, accurate terms which services are covered. The plan contract does not say in clear and accurate terms the situations in which covered dental services would not be covered.We looked at the contract between you and the Plan. We did not see where the contract says that crowns and core build up are not covered. The Plancontract does not clearly state the situations in which crowns are core build upare not covered. This means that the Plandid not follow Medicare rules. Therefore, we decided that the Plan has to pre-approve2 crowns (D2740) for teeth # 6 and 7, and 3 core build up (D2950) for teeth # 6, 7,and 15 to be provided
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forvascular surgery provided on October 31, 2018.You asked thePlan to pay forthe surgery. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the services billed.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 the denied codes is:CPT 34812:Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure)CPT 37242:arterial vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; other than hemorrhage or tumor (congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) We asked our coding 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 surgery. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT code 37242 is not supported.The record does not contain evidence that vascular embolization or occlusion was performed. The procedure report mentions aneurysm repair by coil and graft. According to CPT rules, there is a more specific code for this procedure. CPT code 34812 is not supported. According to CPT rules, this is an add-on code. The record does not show that 34812 was reported with an approved primary procedure code.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 surgery have not been met.Therefore, we decided that the Plan does not have to pay forvascular surgery provided on October 31, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe back brace provided on November 28, 2018.You asked the Plan to reduce the coinsurance forthe back brace. You say that you were told you would have to pay $199.97 out-of-pocket for the brace. 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 40% coinsurance for each out-of-network Medicare-covered prosthetic or orthotic device, including replacement or repairs of such devices, and related supplies. You have been asked to pay $531.38, which is 40% of the allowed amount for the back brace. The allowed amount is $1,328.44. ($1,328.44 x 40% = $531.38). The back brace falls within the "Prosthetic Devices and Related Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance forthe back brace provided on November 28, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient psychiatric care provided from June 11, 2019 to June 15, 2019.You asked the Plan to pay forinpatient psychiatric care. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because inpatient criteria are not met for these dates of service. The Plan also says that they have approved payment for dates of service June 1, 2019 to June 10, 2019, therefore this denial is only for inpatient care provided from June 11, 2019 through discharge on June 15, 2019.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be coveredif 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 pay for inpatient psychiatric care. Our reviewer says that the inpatient hospital psychiatric services do not meet the Medicare criteria for coverage. Our physician reviewer found based upon review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time beyond the dates approved by the Plan as the enrollee was not showing any dangerousness to self or others, had no auditory or visual hallucinations, and no aggressive behaviors, but was calm and cooperative. 
It did not appear medically necessary andreasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates approved by the Plan. The Plan's denial of continued inpatient psychiatric services appears appropriate. It did not appearthat active treatment was taking place on the dates in questions. It did not appears that these services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. The record does not include an individualized treatment plan. The services provided were supervised and evaluated by a physician.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient psychiatric care provided from June 11, 2019 to June 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forradiation therapy (77336, 77387, 77412) provided on July 25, 2019 by out of network provider.You asked the Plan to pay forradiation therapy. You say that you are requesting the payment and seeking a review. You say that per Medicare guidelines reimbursement is 20.9% of billed charges. You further say that you expect the amount of the claim which is $586.03.The Plan denied your request. The Plan says services are not authorized because the provider is a non-network provider who does not work with the member's health plan, and the member was referred by the physician, who also does not work with the member's plan. The Plan also says that the member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 payfor 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 has network providers available who can provide 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 forradiation therapy (77336, 77387, 77412) provided on July 25, 2019 by out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee and billed under code S9328.You asked the Plan to pay forcode S9328. You say that this claim should be paid.The Plandenied your request. The Plan says the Medicare billing criteria are not met because the code billed has a status code indicator of "I" meaning it is not an appropriate code for Medicare billing purposes.The Plan must follow Medicare rules. The rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The rules say that codes with a status indicator of "I = Not valid for Medicare purposes" will be denied payment when reported on a claim.  Medicare uses another code for reporting of and payment for these servicesIn this case, code S9328 has a status code indicator of "I" and is not paid by Medicare. Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee and billed under code S9328.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preparation of oral prosthesis (21076) and the office consultation (99244) provided on July 2, 2019 through July3, 2019.You asked the Plan to pay for the preparation of oral prosthesis and the office consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted didnot include documentation of impression and custom preparation; surgical obturator prosthesis.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 21076 is impression and custom preparation; surgical obturator prosthesis.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 pay for the preparation of oral prosthesis and the office consultation.. Our reviewer says that CPT code 21076 does not meet criteria for billing or reimbursement consideration. The medical documentation submitted for July3, 2019 does not document an impression and custom preparation; surgical obturator prosthesis, therefore this service cannot be validated.  Our reviewer found CPT code 99244 also does not meet criteria for billing or reimbursement consideration. Per the 2019 Physician Fee Schedule, 99244 has a status code of I. This means that 99244 is not valid for Medicare purposes.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 preparation of oral prosthesis and the office consultation. have not been met. Therefore, we decided that the Plan does not have to pay for the preparation of oral prosthesis (21076) and the office consultation (99244) provided on July 2, 2019 through July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you need a shower chair because of your lumbar and knee pain.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forTrain of Four testing (95999) provided on December 13, 2018.You asked the Plan to pay for the Train of Four testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Train of Four isconsidered a bundled procedure and payment for it is included in payment for the general neuromonitoring service.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 pay for the Train of Four testing. Our reviewer says that CPT code 95999 does not meet criteria for billing or reimbursement consideration. Our reviewer found Train-of-four monitoring does not fit the criteria set by CMS and Insurance Carriers for CPT 95999. Train-of-four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable.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 Trainof Four testing have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four testing (95999) provided on December 13, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health physical therapy (PT) services.You asked the Plan to pre-approvethe home PT services. You say that it is felt that the enrollee would benefit from home PT.The Plan denied your request. The Plan says the enrollee does not require this to improve or maintain her condition.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home PT services. Our reviewer says that the documentation does not support that the requested home health care is medically reasonable and necessary. Our physician reviewer found the enrollee is a female who had multiple office visits, pain managements visits, and home health episodes in 2019 for lower back pain. The patient was approved a home health episode on 06/27/2019, 07/31/2019, 08/21/2019 for lower back pain and radiculopathy. On 09/27/2019-09/30/2019 the patient was admitted to the hospital for an L1 Compression Fractureand a TLSO Brace was placed. Per notes she declines surgery. The patient was then discharged to SNF level of care. SNF notes indicated she was ambulating 450 feet with supervision and 4WW. She was at baseline or refusing OT for ADLs. No new signs or symptoms or reason for home health PT was included in the documentation or appeal letter. 
The medical records do not support that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient. The patient has a home exercise program in place and the documentation does not reveal that her functional level requires ongoing skilled home health PT.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 home PT services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient 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 andnecessary in this case. Our physician reviewer found based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires. Based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Based on the provided medical records, the enrollee is getting these services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.You asked the Plan to pre-approveEuflexxa. You say that the provider does not use Orthovisc or Monovisc in their office, so these drugs are not an option.The Plan denied your request. The Plan says the denial of authorization for Euflexxa is correct, because the Plan requires a trial of preferred drugs of Orthovisc and Monovisc before it will approve Euflexxa.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 Euflexxa. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer found you have not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective for you, or would likely have adverse effects.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Euflexxa.