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

We decided that the Plan does not have to pre-approve continued consultation/follow-ups with an out of network (OON) cardiologist.You asked the Plan to pre-approve the continued OON cardiology services. You say that you do not feel it is appropriate to transfer care to a new provider at this time as you are still in the initial treatment phase of your condition and it would be detrimental for you to start with a new provider who is not familiar with your case.The Plan denied your request. The Plan says you may elect to continue to see this provider using your POS benefit; however, there is no medical need to continue OON care. Your needs can be managed by a network cardiologist going forward.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 continued OON cardiology services. Our reviewer says that the documentation does not support that continued OON care is medically necessary at this time. Our physician reviewer found based on the records, the patient had ventricular tachycardia that was treated with sotalol and defibrillator placement after which he was discharged with follow-up scheduled in one month. At this time the patient's ventricular tachycardia has been suppressed with medication and a protective defibrillator has already been placed such that it should be medically safe to transfer the patient's care to an in-network provider. Moreover,there are no documented unique conditions or urgently needed services that would preclude a safe and effective transition to an in-Plan provider. 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 continued OON cardiology services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued consultation/follow-ups with an out of network (OON) cardiologist
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dressings and/or debridement of partial thickness burns
(16025) provided on July 7, 2019.
You asked the Plan to pay for dressings and/or debridement of partial thickness burns. You say that you would
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the
documentation submitted does not indicate the size to support dressings and/or debridement.
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 16025 is dressings and/or debridement of partialthickness
burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body
surface area).
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 dressings and/or debridement of partial thickness burns. Our
reviewer says that CPT code 16025 does not meet criteria for billing or reimbursement consideration. Our
reviewer found per CPC guidelines for code 16025, Procedures 16000 - 16036 refer to local treatment of a
burned surface only. The documentation does not list the percentage of body surface involved and the depth of
the burn.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of dressings and/or debridement of partial thickness burns have not been met.
Therefore, we decided that the Plan does not have to pay for dressings and/or debridement of partial thickness
burns (16025) provided on July 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing rendered on March 3, 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 the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of 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 forthe Guardant360 testing rendered on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management serviceprovided on January 6, 2020.You asked the Plan to pay forhospital discharge day management. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support a hospital discharge day management service more than 30 minutes in duration was performed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providersmust report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutesWe find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted shows a hospital discharge day management of 30 minutes in duration. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay forhospital discharge day management service provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on December 1,
2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation does 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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the record. Specifically, the documentation does not support
that advance care planning services were rendered on the billed date of service. Based on this information, we
decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we
decided that the Plan does not have to pay for advance care planning (99497) provided on December 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder.You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop recorder is medically necessary.The Plan denied your request. The Plan says the requested implantable loop recorder 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 an implantable loop recorder. Our reviewer says that the requested implantable loop recorder is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, obstructive sleep apnea, dyslipidemia, GERD, paroxysmal atrial fibrillation treated with ablation, cardioversions and dofetilide but still subsequent intermittent atrial fibrillation and also cardiomyopathy (LVEF 20-25%). A Holter 01/13/2020 reported atrial tachycardia. A clinic note dated 05/28/20 documents being prescribed apixaban.Based on the records the enrollee has known paroxysmal atrial fibrillation that continues to some extent in spite of ablations, cardioversions and dofetilide. He is already anticoagulated. In this circumstance if identification of additional atrial fibrillation is thought to be medically necessary then prolonged external monitoring (event monitoring) would be most appropriate and recommended. The records do not support the medically necessity for an implantable loop recorder. Coverage criteria are not met since the requested procedure exceeds the enrollee's medical needs at this time.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 implantable loop recorder have not been met.Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray provided by an out-of-network provider on August 12, 2019.You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for an x-ray by the member's primary care provider. The provider is a contract provider. The file does not show that the plan provided notice that an x-ray would not be covered. Under Medicare rules, this means an x-ray is considered approved by the plan. Therefore, we decided that the Plan has to pay for an x-ray provided by an out-of-network provider on August 12, 2019. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and office visit for observation provided on March 17, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray and office visit for observation. You say that you spoke with several Plan representatives who informed you that this treating provider is not your official dentist. You also say that you have been with this dental program for many years, and are current on payments. The Plan denied your request. The Plan says these 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 first intraoral periapical x-ray and office visit for observation provided on March 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 skilled nursing (SN) visits.
You asked the Plan to pre-approve 4 SN visits. 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 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 4 SN visits. Our reviewer says that the
services are not medically necessary. Our physician reviewer found the request for 4 SN visits is not medically
necessary. Skilled nursing services are not required to effectively provide treatment, care, and/or services in
order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the
enrollee's condition and/or prevent deterioration. The request for venipuncture alone is not considered
medically necessary without evidence of another SN need which is not evident in the documentation submitted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 4 SN visits have not been met. Therefore, we decided that the Plan does not
have to pre-approve 4 skilled nursing (SN) visits.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that 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 documentation does not support that you require services at the LTACH that are not available at the acute care hospital currently providing care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra 5% eye drops.You asked the Plan to pre-approveXiidra eye drops.You say that the eye drops are medically necessary.The Plan denied your request. The Plan says this type of medication is not eligible for coverage under the Part B medical benefit.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 pre-approveXiidra 5% eye drops.Benefits for Xiidra eye dropsmay 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 30, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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 physician's services provided on January 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth-completely bony, tooth 15 (D7240) removal of impacted tooth- partially bony, teeth 4, 6 and 12 (D7230) and removal of impacted tooth - soft tissue, teeth 2 and 14 (D7220) and alveoloplasty (D7311).
You asked the Plan to pre-approve the surgical extractions. You say that the enrollee's maxillary sinus is low and they would like to avoid sinus perforations by performing surgical dental extractions The Plan denied your request. The Plan says the requested services do not meet the medical necessity and coverage criteria for dental surgical extractions. Less severe extraction codes should be considered.
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 covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found teeth #2 and #14 had been treatment planned for an extraction of a soft tissue impacted tooth under code D7220. The provided x-rays reveal fully erupted teeth that are not covered by soft tissue. Teeth #4, #12 and #6 have been treatment planned for partial bony impactions under code D7230. None of the noted teeth are partially covered by bone, and are erupted teeth. Tooth #15 is treatment planned for removal of a full bony impaction tooth under code D7240. Tooth #15 is completely erupted with no bone covering the crown of the tooth. Partial and full bony impaction codings require there is bone covering the occlusal surface of the tooth, either fully or in part to be correctly submitted. Alveoloplasty coded as D7311 may be indicated but as the code is associated with concurrent removal of teeth, proper coding would be required to consider the request. Proper ADA code submissions accurately reflecting the clinical situation are required to avoid an adverse determination. Given the requested coding of the planned extractions there is no medical necessity for the requested procedures.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth-completely bony, tooth 15 (D7240) removal of impacted tooth- partially bony, teeth 4, 6 and 12 (D7230) and removal of impacted tooth - soft tissue, teeth 2 and 14 (D7220) and alveoloplasty (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the nebulizer provided on January 29, 2020.
You asked the Plan to waive the deductible for the nebulizer. You say that you cannot afford this bill. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $250 deductible for durable medical equipment.
The nebulizer you asked the Plan to waive the deductible for falls within the "Durable medical equipment
(DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $250 applied towards the nebulizer. This cost sharing is a contractual obligation that
had not been met at the time the nebulizer was received on January 29, 2020. Therefore, we decided that the
Plan does not have to waive the deductible for the nebulizer provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay and the inpatient rehabilitation hospital stay provided from May 2, 2019 to May 22, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay and the inpatient rehabilitation hospital stay. You say that your insurance card does not list the copayment amount for inpatient services. The Plan denied your request. The Plan says the copayment was reduced from $2,250 to $1,350 and that you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment per day, days 1-9 and a $0 copayment per day, days 10-90 for each medically necessary covered inpatient stay. You have been asked to pay a total of $1,350 for the inpatient hospital stay and the inpatient rehabilitation hospital stay. The inpatient hospital stay and the inpatient rehabilitation hospital stay fall within the "Inpatient hospital care" 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.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient hospital stay and theinpatient rehabilitation hospital stay provided from May 2, 2019 to May 22, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveXiaflex (J0775).You asked the Plan to pre-approveXiaflex. You say that this is medically necessary.The Plan denied your request. The Plan says that the documentation does not show criteria for coverage have been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Xiaflex. Our reviewer says that the use of Xiaflex is supported in this case. Our physician reviewer found Xiaflex is the only FDA approved medication for the treatment of eyronie's disease. Criteria for use include the presence of a palpable plaque and at least 30 degrees of penile curvature. The medical records indicate that these criteria have been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xiaflex have been met.Therefore, we decided that the Plan has to pre-approveXiaflex (J0775).