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

We decided that the Plan does not have to pay forthe medical services provided from June 10, 2020, through June 26, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you were not referred for the services, no authorization was obtained and the services rendered were not urgent or emergent services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided from June 10, 2020, through June 26, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gauze rendered on September 23, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says payment is included in the SNF payment.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that these services wereused in a SNF or hospital.Therefore, we decided that the Plan does not have to pay forthe gauze rendered on September 23, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvean arthroscopy with rotator cuff repair (29827) and debridement (29823).You asked the Plan to pre-approvean arthroscopy with rotator cuff repair and debridement. You say that the enrollee needs these procedures.The Plan denied your request. The Plan says that these services are not medically necessary.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 ourphysician 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 an arthroscopy with rotator cuff repair and debridement. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee presents with a history of chronic left shoulder pain, worsening over the past 18 months. His pain is reported grade 7/10 and disrupts sleep. Functional limitations are noted in activities of daily living. Clinical exam findings are consistent with imaging evidence of a full thickness retracted supraspinatus tendon tear, partial thickness infraspinatus and subscapularis tendon tears, moderate biceps tendinosis, and impingement morphology. He has failed to improve with at least 3 months of conservative treatment, including activity modification, medications, home exercise, and steroid injection. Under consideration is a request for left shoulder arthroscopy with rotator cuff repair and debridement. This request is consistent with evidence based medical literature in the setting of function-limiting pain, physical exam findings consistent with imaging evidence of significant rotator cuff pathology, and failure of reasonable conservative treatment. Therefore, this request for left shoulder arthroscopy with rotator cuff repair and debridement is medically reasonable and 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 an arthroscopy with rotator cuff repair and debridement have been met.Therefore, we decided that the Plan has to pre-approvean arthroscopy with rotator cuff repair (29827) and debridement (29823).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 toopen the case again, we will send you a letter.
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 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for mental status changes and a urinary tract infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274), periodic oral evaluation (D0120), and
prophylaxis (D1110) provided on September 15, 2020, by an OON provider.
You asked the Plan to pay for the bitewings, periodic oral evaluation, and prophylaxis. You say that you were
not aware that this provider was out-of-network. The Plan denied your request. The Plan says bitewings
(D0274) is not a covered benefit. The Plan also says that you are responsible for a $25 copayment for the
periodic oral evaluation and prophylaxis, and the OON provider is allowed to bill you the difference between
the billed amount and allowed amount.
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, bitewings are not among those covered
under this benefit. The contract also clearly states that you must pay a $25 copayment for covered preventive
and diagnostic dental services. The Plan also says that the treating provider is OON, and you are responsible
for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not
have to pay for the bitewings (D0274), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on
September 15, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says treatment can occur in a lower level of care, such as outpatient treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if 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 pre-approve the admission. Our reviewer says that
the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found it is
not expected that you would improve in a reasonable period of time beyond the dates in question, as you were
not showing any dangerousness to self or others, auditory or visual hallucinations. There are no aggressive
behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health
plan's denial of continued inpatient psychiatric services appears appropriate.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient mental health facility.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe comprehensive oral evaluation. We decided that the Plan does not have to pay forthe complete series of intraoralx-rays. You asked the Plan to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays. You say that the provider advised that you would be covered for full mouth x-rays.The Plan says that the copayment that you were charged for this service is correct.We decided that the Planhas to pay forthe comprehensive oral evaluation. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The Plan contract clearly states that you are limited to two preventive exams at a $0 copayment.Therefore, we decided that We also decided that the Plandoes not have to pay forthe complete series of intraoral x-rays.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays.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.the Plan has to pay forthe comprehensive oral evaluation.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveacupuncture services.You asked the Plan to pre-approvethe services. You say thatthis is medically necessary.The Plan denied your request. The Plan says that acupuncture is not listed as a covered service by the plan.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 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 services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found you have chronic low back pain, which makes acupuncture a covered service.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 services have been met.Therefore, we decided that the Plan has to pre-approveacupuncture services.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and imaging rendered on August 30, 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 billed correctly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be
billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the services were not billed with the required
bilateral diagnosis 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 eye exam and
imaging rendered on August 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because the records do not show that the enrollee meets the criteria for these facet joint injections.
The Plan follows Medicare rules. Medicare rules state that facet joint injections are covered when all of the
above clinical criteria have been met.
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 facet joint injections. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician
reviewer found the enrollee has radiculopathy and the examination does not show that specific facet joints are
the likely cause of 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 facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided.

You asked the Plan to pay for the self-administered drugs. You say that you were advised that this claim needs to be filed under the pharmacy benefit.The Plan denied your request. The Plan says you were in an outpatient setting, and Medicare nor the Health Plan cover self-administered drugs in the outpatient setting under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided.

Benefits for the self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forMTHFR testing provided to the enrollee on June 16, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a Medicare-covered service.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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer foundMTHFR gene mutation testing is a genetic laboratory test performed on a blood sample to evaluate the presence or absence of a gene mutation involved in folic acid (i.e., vitamin B9) metabolism. Two common MTHFR mutation variants tested are C677T and A1298C. Genetic testing for MTHFR, MTR, MTRR, and MMADHC genes is considered medically necessary if the following clinical conditions are met: CBS testing has been done and is negative; AND the patient has signs and symptoms of homocystinuria. The review has determined that the MTHFR testing provided to the enrollee on June 16, 2020 was not reasonable or 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 the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forMTHFR testing provided to the enrollee on June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can safely be received in other settings.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgery to treat a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the home infusion therapy services provided from September 18, 2020, to October 1, 2020.
You asked the Plan to waive the cost share for the services provided. You say that the prescription should be going through Part D. The Plan denied your request. The Plan says the cost share was 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 20% of the plan-allowed amount for Medicare Part B prescription drugs. You have been asked to pay 20% of the plan-allowed amount for the services provided. The services fall within the Medicare Part B prescription drugs benefit category. Coverage includes drugs you take using durable medical equipment that were authorized by the plan. 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 cost share for the home infusion therapy services provided from September 18, 2020, to October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive dental services rendered on September 8,
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 are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
preventive dental services rendered on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe dialysis services rendered from January 2, 2020 to July 30, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you are being billed by the provider despite having met the deductible.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say aplan 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% coinsurance for Medicare-covered benefits for outpatient dialysis services. Review of the file shows that you received dialysis services from January 2, 2020 to July 30, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered benefits for outpatient dialysis services 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. The Plan's maximum out-of-pocket amount was not met at the time these services were rendered.Therefore, we decided that the Plan does not have to waive the coinsurance forthe dialysis services rendered from January 2, 2020 to July 30, 2020.