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

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (SPECT).You asked the Plan to pre-approve myocardial perfusion imaging (SPECT). 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 follows Medicare rules. Medicare rules say that myocardial perfusion imaging is only covered for certain indications.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 myocardial perfusion imaging (SPECT). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee had shortness of breath and atrial fibrillation.  A Lexiscan was performed that demonstrated possible reversible ischemia. A heart catherization has been approved for coverage. The record indicates that catherization is planned. The enrollee does not meet criteria for the requested myocardial perfusion imaging.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging (SPECT) have not been met.Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on January 15, 2021.

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 had network providers available who could have provided 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 domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on January 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic bronchoscopy for removal of viscous, copious or tenacious secretions from the airways (31645) provided May 31, 2020.You asked the Plan to pay for the bronchoscopy procedure. You say that please see the additional medical records to support the level of care given, as well to support the codes that were billed. Please review the records, process and pay the claim as it has been coded correctly.The Plan denied your request. The Plan says the records do not support the service 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 code 31645 is bronchoscopy with therapeutic aspiration of tracheobronchial tree.We find that CPT code31645 is not supported in the medical record. Specifically, the documentation do not include of bronchoscopy with therapeutic aspiration of tracheobronchial tree. The records show that the plan had made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the bronchoscopy procedure have not been met.Therefore, we decided that the Plan does not have to pay for therapeutic bronchoscopy for removal of viscous, copious or tenacious secretions from the airways (31645) provided May 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 24, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 29, 2020 by an OON provider.You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company.The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that the referring physician is a non-participating provider, and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the subsequent nursing facility care provided on January29, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.

You asked the Plan to pre-approve twelve (12) additional PT visits. You say that you have spinal cord injury, and you still need physical therapy for your whole body. The Plan denied your request. The Plan says the additional PT 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 pre-approve twelve (12) additional PT 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records you appear to have improved with therapy to the point of being able to manage your basic activities of daily living and you have plateaued. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on December 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician visit. You say that your provider depends upon the facility staff to verify eligibility and obtain proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 had network providers available who could have provided 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 a physician visit provided on December 8, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips for the enrollee.

You asked the Plan to pre-approve twelve (12) additional routine transportation trips. You say that the enrollee needs to be seen every 4 to 6 weeks. The Plan denied your request. The Plan says that this request exceeds the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twelve (12) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of twelve (12) routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 29, 2020
.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that treatment was provided to the enrollee in a medically necessary situation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 had network providers available who could have provided 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 an office visit provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement of missing or broken teeth - complete denture
(D5520) provided on June 29, 2020.
You asked the Plan to pay for replacement of missing or broken teeth - complete denture. You say that you
want the Plan to pay for the service. The Plan denied your request. The Plan says you are not covered for this
service when seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of replacement of missing or broken teeth - complete denture have not been met. Specifically,
services were provided by an out-of-network provider without prior authorization. The Plan has contracted
providers available to provide these services. We found no exception that would require the Plan to pay for
these services. Therefore, we decided that the Plan does not have to pay for replacement of missing or broken
teeth - complete denture (D5520) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 13, 2020.

You asked the Plan to pay for critical care services. You say that this is supported in the records.The Plan denied your request. The Plan says this is not documented.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical care services is not documented in the records. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that an LTACH is medically necessary. The Plan denied your request. The Plan says the record does not show that you have a serious medical condition that requires ongoing acute care. Your medical needs can be met at another level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that you are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where care is currently being provided. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition, and the required care does not require a specifically inpatient basis in order to be furnished safely and effectively.

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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Deep Brain Stimulation (DBS).
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that DBS is not reasonable and necessary and is not covered for ET and PD patients with any of the following: Cognitive impairment, dementia or depression, which would be worsened by or would interfere with the patient's ability to benefit from DBS.
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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that in this case the records provided for review indicate that you have been diagnosed with vascular dementia and depression. Both of these conditions could potentially be worsened by or interfere with your ability to benefit from deep brain stimulation (DBS) placement. Therefore, you do not meet the National Coverage Determination (NCD) requirements for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve Deep Brain Stimulation (DBS).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (CPT 64483 and 64484) provided to the enrollee on November 16, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes 64483 and 64484 remain not supported.

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 64483:

injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance(fluoroscopy or CT), lumbar or sacral, single level

CPT 64484:

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records do not support these codes. Transforaminal injection with fluoroscopy is not properly documented and justified in the records. The records do not support the use of code CPT 64483 or CPT 64484.

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 not been met. Therefore, we decided that the Plan does not have to pay for injection services (CPT 64483 and 64484) provided to the enrollee on November 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on June 26, 2020 by an out
of network (OON) provider.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says services
rendered by non-participating providers require 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for mental health services provided on June 26, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy services provided from November 18, 2020, to December 30, 2020.You asked the Plan to waive the copayments for the physical therapy services. You say that copayments were waived during this period.The Plan denied your request. The Plan says the Cost Share Waiver Program did not include the waiving of physical therapy cost share.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient Rehabilitation Services. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services fall within the Outpatient Rehabilitation 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 record shows the Cost Share Waiver Program did not include physical therapy. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy services provided from November 18, 2020, to December 30, 2020.