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

We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 a consultation to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waivethe $225 copayment charged for ambulance transport provided on December 9, 2019.You asked the Plan to waivethis copayment. You say that this ride was only five minutes and should not have this large a copayment.The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the Plan contract agreement.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 $225 copayment for ambulance transport. 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 waivethe $225 copayment charged for ambulance transport provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extractions (D7140 x 11) provided from July 30, 2019 through November 7, 2019 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 allowance.
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 allowance for the eleven dental extractions (D7140 x 11), because the Plan paid for two (2) extractions that were performed on July 30, 2019. Therefore, we decided that the Plan does not have to pay for the dental extractions (D7140 x 11) provided from July 30, 2019 through November 7, 2019 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - porcelain fused to high noble metal (D2750) and core buildup, including any pins when required (D2950) provided on August 26, 2019.
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 the services are not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for crown - porcelain fused to high noble metal (D2750) and core buildup, including any pins when required (D2950) provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on July 25, 2019.
You asked the Plan to pay for the dental services. You say that you have no way of knowing when you have used up your allotted amount and you never know what the dentist charges. The Plan denied your request. The Plan says your services exceed the calendar year maximum.
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. With the payment which totaled $3875.00 you exceeded your calendar year maximum of $3250.00 by $539.00 which is your responsibility. Each explanation of benefits has the plans calendar year maximum printed at the bottom along with how much you have used to date. Therefore, we decided that the Plan does not have to pay for the dental services provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on June 27, 2019 and billed under code 99213.You asked the Plan to pay forcode 99213. You say that this claim should be paid.The Plan denied your request. The Plan says the claim reimbursed per the Outpatient Payment Prospective System (OPPS).  Error code 62 applied which means that code is not recognized per OPPS. 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 Plan provided claim screen prints showing code 99213 created an error on the claim preventing payment. Based on this information, we decided that Medicare rules for coverage of code 99213 have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on June 27, 2019 and billed under code 99213.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefour additional physical therapy visits for the enrollee.You asked the Planto pre-approvethe additional visits. You say that this is medically necessary.The Plandenied your request. The Plansaysonly eight visits can be approved.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 in this case, there is no indication that prior PT has served to provide sustained, significant improvement in function and there is no indication that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not medically 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 the additional visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefour additional physical therapy visits for the enrollee.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approveCPT 19303. We decided that the Plan does not have to pre-approveCPT 15220, 19350, and 19366. You asked the Planto pre-approvethe procedures. You say that this is medically necessary.The Plan says that there is no documentation that the requested facility has a history of treating individual with gender dysphoria.We decided that the Plan has to pre-approveCPT 19303. The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for CPT 19303 (bilateral). Our reviewer says that the requested procedure is medically reasonable and necessary.  Our physician reviewer found that the enrollee has gender dysphoria, and is in the transition to a male chest appearance. There isevidence of abnormal breasts for a male despite the use of hormonal therapy, which had begun in November of 2017 and would not likely resolve with continued therapy. The planned surgery is not consistent with cosmetic surgery, but reconstructive surgery as the aim is to approximate a more normal male appearance. His current status is one an abnormal male appearance. CPT 19303 would provide the necessary treatment of the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 19303 have been met.Therefore, we decided that the Plan has to pre-approveCPT 19303. We also decided that the Plan does not have to pre-approveCPT 15220, 19350, and 19366.The Plan follows Medicare rules. Medicare rules say that cosmetic surgery is not a covered benefit.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 for the remaining services. Our reviewer says that the remaining procedures are medically reasonable and necessary. Our physician reviewer found that the plan is not to place nipple grafts, and thus the CPT codes chosen -15220 and 19350 -would not be medically necessary. An additional code -CPT 19366 (breast reconstruction) has not been supported either.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 15220, 19350, and 19366 have not been met.Therefore, we decided that the Plan does not have to pre-approveCPT 15220, 19350, and 19366.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network outpatient mental health care provided on October 2, 2019.You asked the Plan to pay forout of network providers. You say that no one told you that you needed prior authorization.The Plan denied your request. The Plan says the Plan contract clearly states prior authorization is required both for out of network providers and in particular for outpatient mental health care.Medicare rules say thatplans 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forout of network outpatient mental health care provided on October 2, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea CT scan of the soft tissue neck.You asked the Plan to pre-approvea CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested CT scan is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve a CT scan. Our reviewer says that the documentation supports that the requested CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a neck mass. This neck mass has the possibility of being a thyroid nodule. The exact etiology of the neck mass is not certain. Given this uncertainty and the possible influence of the mass on the veins of the neck and the clinical implications with regard to venous thrombosis and anti-coagulation therapy, the enrollee meets criteria for the requested CT scan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have been met.Therefore, we decided that the Plan has to pre-approvea CT scan of the soft tissue neck.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcode A4351 KX GL (450 units) billed to the enrollee for date of service September 5, 2019.You asked the Plan to pay forthis claim. You say that these supplies were provided to the enrollee and should be covered by the Plan.The Plan denied your request. The Plan says code A4351 KX GL (450 units) remains not supported. Healthcare Common Procedure Coding System (HCPCS) code A4351 represents intermittenturinary catheter; straight tip, with or without coating. The medical records indicate that intermittent urinary catheter; "coude tip", with or without coating was ordered and delivered. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code which is A4352 that should be used. The Plan notes several attempts were made to contact the provider for revised or corrected claim information. 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, code A4531 has created an error on the claim preventing payment.The Plan states a corrected claim would be reviewed if submitted. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forcode A4351 KX GL (450 units) billed to the enrollee for date of service September 5, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune device and transducers (E0766).
You asked the Plan to pre-approve an Optune device and transducers. 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 follows Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when specific criteria is met. 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 Optune device and transducers. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is diagnosed with anaplastic astrocytoma, not glioblastoma multiforme. Coverage criteria for Optune therapy is not 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 an Optune device and transducers have not been met. Therefore, we decided that the Plan does not have to pre-approve an Optune device and transducers (E0766).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by out of network (OON) provider
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the physician provided medically necessary services to the member in good faith. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider on October 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from September 6, 2017 to November 4, 2017.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claim submitted was incomplete. The Plan states The Final claim with the correct HHRG code is required to process and pay claims. The HHRG code on the claims indicates there were Non-Routine Supplies (NRS) provided, but are not submitted on the claim; therefore, per the Medicare guidelines the plan is upholding the claim denials as the provider did not bill with an appropriate home health data.
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, an incomplete claim was submitted for payment. Based on the information provided with the case file, Medicare rules for coverage of this service have not been met. It should be noted that this office received a corrected claim and claim records with a request to reprocess the claim for payment. We do not reprocess corrected claims. This information needs to be sent directly the health plan. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee from September 6, 2017 to November 4, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on October 17, 2019.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 17747, 2019.
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 enrollee needs an IRF level of care because she is a fall risk. You say that IRF care would better help the enrollee to return to her everyday life independently. The Plan denied your request. The Plan says the enrollee is able to perform daily living activities independently and her medical conditions are stable. The Plan says that the enrollee does not have wounds that require skilled care. The Plan says that the enrollee does not need a multidisciplinary team or visits from a physician. The Plan says that the enrollee does not need to participate in physical therapy or occupational therapy five times per week, and her care can be handled in a less intensive setting.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on January 3, 2020. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service is not a covered benefit under your contractual policy. 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 the electric stimulation therapy (97014) provided on January 3, 2020.