Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (G0299)
You asked the Plan to pre-approve the skilled nursing services. You say that the services are medically necessary. The Plan denied your request. The Plan says services are custodial at this time and coverage criteria is not met.
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 skilled nursing services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found there is no skilled nursing need. Care appears custodial and does not warrant in-home skilled professional(s). 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits (G0299)
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says these additional visits would be excessive.
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 the additional 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 the requested additional therapy beyond what was approved by the health plan is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has been authorized sufficient and extensive therapy for her condition and should be able to transition to an independent home exercise program. Her functional deficits not require the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist beyond what was approved by the health plan. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 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 the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
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 services are not medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not indicate that his functional status requires this therapy on an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on July 8, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the billed code does not appropriate reflect the services
provided.
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 99350 is Home visit for the evaluation and management
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face
with the patient and/or family.
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 home visit. Our reviewer says that CPT code 99350 does
not meet criteria for billing or reimbursement consideration. Our reviewer found 99350 is a Evaluation and
Management code used to report services, perform by a provider or other qualified health care professionals. A
Resident Nurse is not considered a qualified health care professional for this 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 home visit have not been met. Therefore, we decided that the Plan does not
have to pay for a home visit (99350) provided on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on March 9, 2020You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral ankle foot orthoses (L1971) provided to the enrollee on March 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the nutritional supplements (D9999) provided February 22, 2019 to June 26, 2019.
You asked the Plan to issue reimbursement for the nutritional supplements. You say that the nutritional supplements are medically necessary. The Plan denied your request. The Plan says nutritional supplements are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pay for are nutritional supplements. Therefore, we decided that the Plan does not have to issue reimbursement for the nutritional supplements (D9999) provided February 22, 2019 to
June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical boot/shoe, each (L3260) provided to the enrollee on January 27, 2020.
You asked the Plan to pay for foot orthotics. You say that the shoe wasn't part of a brace so GY modifier is the correct modifier. The Plan denied your request. The Plan says the Medicare rules have not been met.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Per the above Medicare guidelines HCPCS code L3260 did not meet any of the foot care exclusions and was denied as a service not covered. Therefore, we find the Medicare rule for payment of HCPCS code L3260 for January 27, 2020, has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for surgical boot/shoe, each (L3260) provided to the enrollee on January 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your endurance level can tolerate an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 speech therapy home health services.You asked the Plan to pre-approve speech therapy home health services. 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. 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 speech therapy home health services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation supports that the enrollee is tolerating their current diet. There is no evidence that the enrollee has aphasia or dysarthria. The documentation does not support that the enrollee meets criteria for the requested speech therapy 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 speech therapy home health services have not been met.Therefore, we decided that the Plan does not have to pre-approve3 speech therapy home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met at a lower level of care. 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 an 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 resin-based composite - two surfaces, anterior (D2331) and resin-based composite - one surface, anterior (D2330 x 2) provided on February 25, 2020 by an in-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because your claim history shows that you have had one amalgam filling on February 4, 2020 and a second amalgam filling on February 11, 2020. These two fillings have exhausted your benefit for fillings for calendar year 2020. Your EOC states, Restorations (Fillings) - Amalgam and/or Composite - Frequency/Limitations - Two (2) procedures per calendar year. Therefore, we decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior (D2331) and resin-based composite - one surface, anterior (D2330 x 2) provided on February 25, 2020 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on January 14, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 prophylaxis - adult (D1110) provided on January 14, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 7, 2020.You asked the Plan to pay forthe dental services. You say that the services denied incorrectly.The Plan denied your request. The Plan says Medicare does not cover routine dental services and the Plan does not cover this service.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. Medicare does not cover routine dental services. Furthermore, this service is not listed in your EOC as a covered benefit; therefore, it is not covered with your Plan.Therefore, we decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV (K0800), for the enrollee.You asked the Plan to pre-approve the POV. You say that the enrollee needs the motorized scooter for safe ambulation.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the POV have not been met. The member had a power scooter delivered to their home on May 10, 2018. Medicare allows purchasing of equipment once every five (5) years and that is only if the equipment cannot be repaired.Therefore, we decided that the Plan does not have to pre-approve the POV (K0800), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from April 10, 2018 through December 19, 2018.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the primary insurer paid for your claim.
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. Review of the file sows that you have a primary dental insurer. The primary insurer, paid the allowed amount for all dental services in dispute and the remaining amount was adjusted from your account per primary insurer's claim processing. Since your primary dental insurer paid the dental claims with $0 enrollee responsibility, you did not pay for any dental services out-of-pocket. Therefore, the health plan is unable to reimburse you since your primary insurer paid your claim, not you. Therefore, we decided that the Plan does not have to pay for the dental services provided from April 10, 2018 through December 19, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency generated water vapor therapy (CPT 53854)
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity for this procedure.
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 the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is not covered if the enrollee has prostate cancer. Additionally, an IPSS score of greater than 13 was not provided. Also, a maximum urinary flow rate (Qmax) of 15 mL/s or less was not provided. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency generated water vapor therapy (CPT 53854).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy (97140) provided by a chiropractor on March 3, 2020.
You asked the Plan to pay for manual therapy. You say that this was covered in the past. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for manual therapy (97140) provided by a chiropractor on March 3, 2020.