Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar vertiflex interspinous and/or interlaminar
device.
You asked the Plan to pre-approve lumbar vertiflex interspinous and/or interlaminar device. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are 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 pre-approve lumbar vertiflex interspinous and/or
interlaminar device. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found you have spinal stenosis. The requested
device is considered experimental at this time. More research is needed to show the safety and efficacy.
Therefore, you do not 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 lumbar vertiflex interspinous and/or interlaminar device have not been met.
Therefore, we decided that the Plan does not have to pre-approve lumbar vertiflex interspinous and/or
interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942) rendered by
the out of network (OON) provider on November 6, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not
have to pay for the chiropractic manipulative treatment (98942) rendered by the out of network (OON)
provider on November 6, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee had a CT in December of 2019
that showed a new pleural-based nodule in the left lower lbone. The requested CT scan is reasonable and
medically necessary for a six month follow up.
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 been met. Therefore, we decided that the Plan has to preapprove
a computed tomography (CT) scan of the chest.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 physical therapy visits and 12 occupational therapy visits.
You asked the Plan to pre-approve 18 physical therapy visits and 12 occupational therapy visits. You say that you were unable to go for 3 months due to the office being closed. You say that every time there is a break in therapy, you lose progress. The Plan denied your request. The Plan says the additional visits are not medically necessary.
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 pay for 18 physical therapy visits and 12 occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had extensive therapy and was trained in a home exercise program. Our physician reviewer also found that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 additional physical therapy visits and 12 occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 physical therapy visits and 12 occupational therapy visits.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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 the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on November 26, 2019 to January
28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the provider
or facility.
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 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 vision services provided on November 26, 2019 to
January 28, 2020 by an out of network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met for IRF admission. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased February 13, 2020.
You asked the Plan to pay for the hearing aids. You say that the enrollee was seen in your office and invested in a right and left Resound Linx 7 3D receiver in the ear. He cannot hear well without hearing aids. The price was $5740. The Plan denied your request. The Plan says enrollee's must receive their care from a network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the services are rendered by an in-network provider. You can find this information on page 53 of the plan's 2020 Evidence of Coverage. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the specialist office visits provided on
January 23, 2020 to February 11, 2020.
You asked the Plan to reduce the copayments for the specialist office visits. You say that you are being charged
a copayment when you see your primary care physician. You say you should not have a 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 $20
copayment for services obtained from an in-network specialist. Or, under certain circumstances, by a nurse
practitioner or physician's assistant or other non-physician's assistant or other non-physician health care
professionals.
You have been asked to pay a $20 copayment for the each of the specialist office visits. The specialist office
visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The
record shows this provider specializes in internal medicine infectious diseases.
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 copayments for the specialist office visits provided on January 23, 2020 to
February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nail trimming services received from an out-of-network provider on March 3, 2020.
You asked the Plan to pay for the services. You say that you have out-of-network coverage now, and this should be approved. The Plan denied your request. The Plan says the ANOC states that for routine foot care for members with certain medical conditions, the point-of-service out-of-network for routine podiatry is not available.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Routine foot care from out-of-network providers is not covered by the plan. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for nail trimming services received from an out-of-network provider on March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography rendered on October 24, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that procedure code 77066 was previously paid by the
Plan on a separate claim for the same date of service. 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 diagnostic mammography rendered on
October 24, 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not 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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does
not currently require intensive physician and nursing oversight only in an IRF. The documentation does not
support that your functional status or activity tolerance requires an intensive rehabilitation therapy program
provided in an IRF. Medicare coverage criteria for IRF care are not met.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitting of spectacles (92341) provided on February 27, 2020.
You asked the Plan to pay for the fitting of spectacles. You say that you would like reconsideration because the
providers visit should fall under the authorization that the nursing home has for the stay of the member. The
Plan denied your request. The Plan says CPT code 92341 is a non-covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for eye exams for the
purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the fitting of spectacles have not been met. Specifically, per the Physician Fee Schedule, CPT code
92341 has a status indicator of N. This means that CPT code 92341 is a non-covered service. The Plan contract
does not indicate that the fitting of spectacles is a covered benefit. Therefore, we decided that the Plan does not
have to pay for fitting of spectacles (92341) provided on February 27, 2020.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided you do not require treatment in an intensive rehabilitation therapy program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the nail avulsion provided on February 28, 2020.
You asked the Plan to reduce the copayment for the nail avulsion. You say that you were charged a higher price for the nail trimming. You say you would like this claim reviewed. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for each Medicare-covered podiatry visit. The enrollee has been asked to pay a $35 copayment for the nail avulsion. The nail avulsion falls within the each "Podiatry services" benefit category. The medical record shows a nail avulsion was performed during this visit.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the nail avulsion provided on February 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve laser skin therapy.
You asked the Plan to pre-approve laser skin therapy. You say that you are appealing with records. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because there is no indication of a trial and failure of a 3-month course of therapy with topical treatment and/or phototherapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 laser skin therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found excimer laser treatment is the standard of care for patients with psoriasis resistant to the first line medications, such as 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 laser skin therapy have been met. Therefore, we decided that the Plan has to pre-approve laser skin therapy.
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.