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

We decided that the Plan does not have to pay for the psychotherapy provided by an out-of-network provider
on May 19, 2020.

You asked the Plan to pay for the psychotherapy. You say that the doctor depends on the hospital staff to verify
eligibility and obtain proper authorization. You say that the physician provided medically necessary services
and payment for the claim should be processed at the maximum amount allowed. 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 psychotherapy provided by an out-of-network
provider on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peripheral nerve destruction to the right knee.
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee. You say that the enrollee is trying to avoid surgery. The Plan denied your request. The Plan says this procedure is considered experimental and investigational.
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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) right knee have not been met. Therefore, we decided that the Plan does not have to pre-approve peripheral nerve destruction to the right knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mouth guard/TMD appliance.

You asked the Plan to pre-approve the mouth guard. You say that you would benefit from a mouth guard. 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 pre-approve the
mouth guard/TMD appliance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network provider.
You asked the Plan to pre-approve ophthalmology services. You say that the requested out-of-network facility is able to provide you with a complete test and evaluation of the optic nerve. The Plan denied your request. The Plan says the requested service is available within your health plan network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology procedure provided on August 25, 2020.

You asked the Plan to pay for the cytopathology procedure. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the cytopathology procedure provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, resin-based composite, core buildup, including any pins when required, and crown provided from August 13, 2020, to November 10, 2020 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, resin-based composite, core buildup, and crown. You say that this treating provider should still be in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your plan does not have OON benefits.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, resin-based composite, core buildup, including any pins when required, and crown provided from August 13, 2020, to November 10, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a colonoscopy provided on
December 21, 2020.
You asked the Plan to waive the deductible and copayment for a colonoscopy. You say that you thought that
this would qualify as a colonoscopy screening and disagree with the charges. The Plan denied your request.
The Plan says the claims were processed correctly, and you are being charged the correct 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 a $750 deductible. Your contract with the Plan also clearly says that
after the $750 deductible has been met, enrollee's must pay a $125 copayment for outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers.
The medical records show that you had polyps removed during a colonoscopy on December 21, 2020.
Therefore, the colonoscopy is considered a diagnostic colonoscopy, not preventative, and you are responsible
to pay you share of the cost-sharing charges. The record shows that you had only paid $515.46 toward the $750
deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible
balance of $234.54. Now that the deductible has been met, you are also responsible to pay the $125 copayment.
The total amount you owe is: $359.54.
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit
category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible and a $125 copayment for outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at
the time a colonoscopy was received on December 21, 2020. Therefore, we decided that the Plan does not have
to waive the deductible and copayment for a colonoscopy provided on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this request is medically necessary. The Plan denied your request. The Plan says it has not been one year since the enrollee's last LDCT.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all criteria listed in the Medicare rules section. We reviewed the file and the Medicare rules. We find that it has not been twelve months since the enrollee's last LDCT scan in August 2020. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 4, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation.
The file shows that lab procedure codes 80157, 80177, 80201, 80162, 80159, and 80173 were billed. We find
that codes are not supported in the medical record. These lab services are performed using a blood specimen.
The records provided shows the enrollee provided a urine specimen. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the lab services provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that you are not treated with insulin and are not testing your blood sugar levels four or more times per day. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you have been seeing a cardiologist for 6 months. The Plan denied your request. The Plan says there are in network providers available to render the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration (D3431).
You asked the Plan to pre-approve the biologic materials. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
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 pre-approve biologic materials to aid in tissue regeneration (D3431).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for annual nursing facility assessment services coded 99318 provided on October 20, 2020.

You asked the Plan to pay for annual nursing facility assessment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 99318 is evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate 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 patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient's facility floor or unit.

We find that CPT code 99318 is not supported in the medical record. Specifically, this service is reported on an annual basis. Review of the file shows that the enrollee previously received this service on October 22, 2019. 365 days (one full year) had not passed since the enrollee previously received this service. Based on this information, we decided that Medicare rules for coverage of annual nursing facility assessment services have not been met. Therefore, we decided that the Plan does not have to pay for annual nursing facility assessment services coded 99318 provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.
You asked the Plan to pre-approve the consultation. You say that you have a history with this doctor's group prior to joining Medicare. You say that you refuse to go anywhere else besides this doctor. The Plan denied your request. The Plan says in-network providers are available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and crown (D2750).

You asked the Plan to pre-approve the core buildup and crown. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says core buildup is not covered under your benefit plan. The Plan also says that the crown benefit has a limit to two in a calendar year, and you have already received 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, core buildup, including any pins when required (D2950) is not among those covered under this benefit. The contract says that crowns are limited to 2 per calendar year. The record shows that you received two crowns (D2750 x2) on February 5, 2021 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the use of radiofrequency ablation for pain management for sacroiliitis has not been shown to provide a clear long-term benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary/investigational. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prosthetics to be provided by an out of
network provider.

You asked the Plan to pre-approve replacement prosthetics from an out of network provider. You say that you
need a replacement prosthetic. The Plan denied your request. The Plan says the services are available within the
network.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve lower extremity
prosthetics to be provided by an out of network provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for non-surgical management of humeral fracture, T2 spinal fracture and several rib fractures after a motor vehicle collision. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.