Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (CPT code 90837) provided to the enrollee on December 14, 2020, by a non-contracted provider.

You asked the Plan to pay for the psychotherapy services. You say that you rendered treatment to the enrollee in good faith that the service will get reimbursed. The Plan denied your request. The Plan says the provider did not make attempts to verify the enrollee's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services. The Plan states there is no evidence of plan directed care and the enrollee was not receiving skilled services or inpatient services during this time. The Plan states the provider did not provide good cause for why prior authorization was not requested.

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 psychotherapy (CPT code 90837) provided to the enrollee on December 14, 2020, by a non-contracted provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the guidelines do not support PET imaging to detect a lesion less than eight millimeters.

The Plan must follow Medicare rules. Medicare rules say that PET 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 was correct in denying the request to pre-approve the PET scan. Our physician reviewer found CMS provides coverage for one FDG PET study for enrollees who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the treating physician determines that the study is needed to determine the location and/or extent of the tumor for designated therapeutic purposes related to the initial treatment strategy. This has not demonstrated in the medical records available in the case file. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance angiography (MRA).

You asked the Plan to pre-approve an MRA. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that MRA is only covered for certain indications.

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 MRA. Our reviewer says that the
documentation does support that the requested services are medically reasonable and necessary. Our physician
reviewer found you were diagnosed with moderate chronic intermittent tension-type headache, not intractable,
and migraine. The headaches are described as vertigo, sensitivity to noise, feeling of pressure on top of head,
and shock-like sensations affecting the left occipital region radiating anteriorly. Previous imaging including
computed tomography scan (CT) head have been inconclusive. Considering prior imaging was inconclusive
and symptoms are persistent and failing conservative care, it is reasonable to use MRA to investigate further.
Therefore, you meet criteria for the requested MRA.

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 MRA have been met. Therefore, we decided that the Plan has to pre-approve
a magnetic resonance angiography (MRA).

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: 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 the enrollee would benefit from inpatient rehab. 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 a neck injury after a fall. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on December 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you were told this specialist was in-network. You say that you later found out they were out-of-network. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there are participating providers available for these services.

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 specialist services provided on December 23, 2020 by an out of network (OON) 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.

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 you can safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis, abdominal pain, and pneumoperitoneum. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 9, 2020, to November 11, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal the self-administered drugs. The Plan denied your request. The Plan says the self-administered drugs are not Part B covered.

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 pay for the self-administered drugs provided from November 9, 2020, to November 11, 2020.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
January 29, 2021.

You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says that the Plan paid the correct amount of $250 for the eyewear benefit allowance.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has paid the correct amount of $250 for the eyewear benefit allowance. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-ONE.

You asked the Plan to pre-approve Synvisc-ONE. You say that the requested Synvisc-ONE is medically necessary. The Plan denied your request. The Plan says the requested Synvisc-ONE is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Synvisc-ONE. Our reviewer says that the requested Synvisc-ONE is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Synvisc-ONE is FDA-approved for the enrollee's diagnosis. The use of Synvisc-ONE for hip osteoarthritis is not supported by one of the major drug compendia or by clinical research that appears in a CMS approved medical journal. Documentation in Drugdex/Micromedex includes a strong recommendation against use of intra-articular hyaluronic acid for hip osteoarthritis. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Synvisc-ONE is safe and effective and otherwise reasonable and necessary for this enrollee's hip osteoarthritis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-ONE have not been met. Therefore, we decided that the Plan does not have to be pre-approven Synvisc-ONE.
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's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 pneumonia and hypoxemia. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 1, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010 x 4), the cone beam CT capture with interpretation (D0382 x 2), and the additional simple extractions (D7140 x 5) provided from February 19, 2020, to November 11, 2020 by the out of network provider.

You asked the Plan to pay for the implants, cone beam CT, and 5 additional extractions. You say that you needed the implants. You say that this was an emergency. You also say that this has placed a financial burden on you. The Plan denied your request. The Plan says implants are not listed as covered services. The Plan says that cone beam CT are not listed as covered services. The Plan says that 2 extractions per year are covered with a 45% coinsurance when performed out of network. The Plan also says that the frequency limit 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, the implants and cone beam CT are not among those covered under this benefit. Although extractions are listed as covered, the frequency limit has been exceeded. The record shows that the paid for the extractions for teeth # 2 and 4 that you received on July 2, 2020. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body (D6010 x 4), the cone beam CT capture with interpretation (D0382 x 2), and the additional simple extractions (D7140 x 5) provided from February 19, 2020, to November 11, 2020 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant removal (20680) provided on November 13, 2020.

You asked the Plan to pay for an implant removal. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

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, we have confirmed that code 20680 has a bundled relationship with code 27447 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an implant removal (20680) provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 17000) provided on May 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 an office visit (99214, 17000) provided on May 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee can control any power options through their own individual switches.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.