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

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 and 99152 provided on August 29, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes 99153 and 99152 are not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the code 99152 cannot be verified. Code 99153 is denied due to the primary service (code 99152) being denied). Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 and 99152 provided on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced power wheelchair with specialty features (K0858, E1028, E1002, E2310, K0040, E2363, E2617, E2609, E0955 and E1028).
You asked the Plan to pre-approve the power chair and specialty features. You say that the services are medically necessary. The Plan denied your request. The Plan says Medicare Part B does not cover DME intended for use in a Skilled Nursing Facility setting.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the power chair and specialty features is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve an advanced power wheelchair with specialty features (K0858, E1028, E1002, E2310, K0040, E2363, E2617, E2609, E0955 and E1028).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat heart sonogram/echocardiogram for the enrollee. You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found on 1/30/2020, the enrollee was noted to have a thickening on one leaflet of his mitral valve, which was new since July 2019. A repeat TTE has been ordered to evaluate whether or not there have been any changes in this thickening. While the enrollee is not reporting new/worsening symptoms, it is medically necessary and reasonable to monitor this newly reported thickening, to determine ongoing management. 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 been met. Therefore, we decided that the Plan has to pre-approve a repeat heart sonogram/echocardiogram for the enrollee. 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: Favorable

We decided that the Plan has to pay for the services you received from February 8, 2018, to April 9, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider does not accept Medicare. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan says that this provider does not accept Medicare, but has not provided documentation showing this. This provider is an MD of psychiatry, which is a Medicare-eligible specialty. The plan has not submitted documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the services you received from February 8, 2018, to April 9, 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 a routine eye exam (92004) provided on January 3, 2020.
You asked the Plan to pay for a routine eye exam. You say that you did not know you had to go through for vision services. The Plan denied your request. The Plan says vision services must be received from a select provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by a provider for these services. Out-of-network routine vision services are not covered. We looked at the file and the Plan's rules. The provider for the service at issue is not a select provider. Based on this information, we decided that the Plan's rules for coverage of a routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye exam (92004) provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level office visit for a Lupron shot.
You asked the Plan to pre-approve the tertiary level visit. The Plan denied your request. The Plan says this can be provided at a lower level of care.
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 tertiary level visit. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that it is not medically necessary to perform the Lupron shot in a tertiary care setting. A non-tertiary urologist is available to perform this service. 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 tertiary level visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level office visit for a Lupron shot.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64493 and 94494). You asked the Plan to pre-approve the facet injections. You say that you would like reconsideration because this service is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says records do not show that the members pain is localized to the neck or back or if the pain does not travel to other areas of the body. 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 facet injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has co-existing radicular and SI joint pain. The LCD exclusion criteria specifically address that other pain generators of low back pain have to be excluded first. There are clearly other pain generators on-going here. 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 facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections (64493 and 94494).
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 you require the IRF services. The Plan denied your request. The Plan says your medical conditions are stable and do not require daily physician oversight. The member's care needs can be provided at a lesser level of care such as Skilled Nursing Facility or Home Health.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Treatment in a skilled nursing facility is a more appropriate level of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 29, 2020 through February 3, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you disagree with the processing of the claim. The Plan denied your request. The Plan says the copayment applied correctly.
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 $350 copayment per day, days 1 to 5 at an in-network inpatient hospital. You have been asked to pay a $1,750 copayment for the inpatient stay. ($350/day x 5 days = $1,750). The inpatient stay falls 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 for the inpatient stay provided from January 29, 2020 through February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Durolane. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 13, 2020. 
 
You asked the Plan to pay for the physician's services. You say that you said you called the physician's office and were told that they accepted your insurance plan. The Plan denied your request. The Plan says you 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 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring provided to the
enrollee on January 13, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says diagnostic testing requires prior authorization from out-of-network providers.
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 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 intraoperative neurophysiology monitoring
provided to the enrollee on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 30, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that this was the only doctor you could see in a
timely manner. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says
these services were not urgent or an emergency.
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 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 physician services provided on April 30, 2019 by
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on August 21, 2019 by an out of network (OON) provider. You asked the Plan to pay for wound care. You say that these services were provided in a skilled nursing facility. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound care provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0425). 
 
You asked the Plan to pre-approve a shower chair. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0425).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says in the absence of a clinical trial, PET scans are approved only for the differential diagnosis of frontotemporal dementia (FTD) from Alzheimer's disease (AD) under specific requirements.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found CMS guidelines for brain PET scan specify there must be a differential diagnosis of Alzheimer Dementia versus FTD for PET scan of the brain to be covered. The guidelines specify that when there is a question of Lewy Body Dementia PET scan continues to be a Nationally non covered scan per CMS guidelines. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided November 9, 2019 to November 14, 2019. You asked the Plan to pay for the inpatient psychiatric services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the documentation does not support that the services received were medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on October 31, 2019 with Bipolar Disorder, Severe with Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as the enrollee did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment described as pleasant while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self or others but was compliant with treatment. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. Therefore, the enrollee did not meet criteria for the inpatient psychiatric services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided November 9, 2019 to November 14, 2019.