Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan does not have to pre-approve 6 additional fractions of Intensity-Modulated Radiation
Therapy (IMRT).
You asked the Plan to pre-approve the 6 additional fractions of IMRT. You say that The 6 additional fractions
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the 6 additional fractions of IMRT. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found this enrollee's 6-fraction course of treatment would treat the primary sites and
metastases in one treatment course with IMRT. This treatment would be furnished in accordance with accepted
standards of medical practice.
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 6 additional fractions of IMRT have been met. Therefore, we decided that
the Plan does not have to pre-approve 6 additional fractions of Intensity-Modulated Radiation Therapy (IMRT).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional non-emergency transportation, taxi (A0100).

You asked the Plan to pre-approve the additional trips. You say that you have several medical appointments with your specialists to get the go ahead for surgery. You do not drive, and the closest relative's vehicle does not work. The Plan denied your request. The Plan says this request exceeds the benefit maximum of 24 trips.

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 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the additional non-emergency transportation, taxi (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Exome sequence analysis (81415).
You asked the Plan to pre-approve the Exome sequence analysis. You say that this service is medically necessary in order to determine a diagnosis for physical therapy. The Plan denied your request. The Plan says this testing is 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 the Exome sequence analysis. Our reviewer says that the local coverage determination states that diagnosis and monitoring non-Cancer indications is excluded. Our physician reviewer found the member's indicated diagnosis is non-cancer related. The elements of the coverage criteria are not satisfied. 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 Exome sequence analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Exome sequence analysis (81415).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits.

You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says you have achieved expected outcomes therapy sessions and/or met reasonable goals for function.

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 six (6) 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The records do not demonstrate 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 by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist 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 six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), and the fillings (D2330 x 2) provided on January 13, 2021.
You asked the Plan to reimburse you for the dental services. You say that you attempted to find the providers office online but could not find them listed. You say that you contacted the provider's office directly. You say that you were advised that they accepted your insurance. You also say that only after you received the denial did the office advise that they do not accept your specific HMO plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider that is not part of our supplemental dental network is 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 and the services are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), and the fillings (D2330 x 2) provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 7, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you do not understand why this service was denied. The Plan denied your request. The Plan says this service is 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 periodontal maintenance provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 6, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from December 4, 2020, to
December 15, 2020.

You asked the Plan to pay for the services provided. You say that your policy states that chiropractic visits are
covered. The Plan denied your request. The Plan says the office visit and electrical stimulation do not meet the
requirements for approval.

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 file shows that you received an office visit on December 4, 2020. You also received electrical stimulation
on December 4, 8, 9, 11, and 15, 2020. These services are not manual manipulation of the spine. Services other
than manual manipulation, when provided by a chiropractor, are not covered. Therefore, we decided that the
Plan does not have to pay for the chiropractic services provided from December 4, 2020, to December 15,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0013M) provided November 10, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. The test performed is not a covered service. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0013M) provided November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine provided on September 14, 2020.

You asked the Plan to pay for the Tdap vaccine. You say that you are at high risk for infectious diseases. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine provided on September 14, 2020.

Benefits for the Tdap vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home 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 the enrollee appears to be improving but requires additional short-term acute care services for further stabilization which can be safely received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is not stable for transfer to an LTACH.

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. The patient appears to be worsening and unstable requiring short-term additional acute care services which can be safely provided at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you cannot afford to pay for this. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, comprehensive oral evaluation and is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on March 23, 2019 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection provided by an out-of-network provider on October 15, 2020.
You asked the Plan to pay for the spinal injection. You say that the provider shouldn't deny medically necessary services based on the patient's enrollment. You say that the denial should be overturned and processed in-network. The Plan denied your request. The Plan says prior authorization was required but 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 spinal injection provided by an out-of-network provider on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on February 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for wound care services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that prior authorization was not obtained by the member's primary care physician.
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 wound care services provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on October 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an oxygen concentrator. You say that you would like this claim reprocessed and paid. You say that you were told you would be reimbursed. The Plan denied your request. The Plan says this equipment could have been purchased from an in-network provider. The Plan says that you must use an in-network provider.
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 durable medical equipment provided on October 29, 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 the problem focused limited oral evaluation and panoramic x-ray provided on November 25, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that the enrollee signed an agreement acknowledging that they would be responsible for these services.
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 problem focused limited oral evaluation and panoramic x-ray provided on November 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy.

You asked the Plan to pre-approve the additional speech therapy. The Plan denied your request. The Plan says
that the member has met the discharge criteria based on lack of functional progress.

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 speech therapy. 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 speech therapy is generally accepted as specific
and effective therapy for a patient with developmental disorder of speech and language; however, the available
records do not support that additional speech therapy by a professional speech therapist is required to safely
and effectively provide treatment for the enrollee in this case. While the enrollee's verbal responses show more
frequent linguistic flexibility, the documentation does not support that the specialized skill, knowledge and
judgment of a qualified therapist are 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 speech therapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional speech therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on October 20, 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 procedure code K0553 is 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 code K0553 is supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service. We find that CPT code K0553 is not supported in the medical record. Specifically, there are no submitted records for the date of service at issue. 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 continuous glucose monitor supplies rendered on October 20, 2020.