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

We decided that the Plan does not have to pre-approve a consultation for an oral appliance.You asked the Plan to pre-approve a consultation. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that oral devices to treat dental conditions are non-covered.Review of the file shows that you are requesting a consultation for an oral appliance. Since the oral appliance is not covered, the request for the consultation is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a consultation have not been met.Therefore, we decided that the Plan does not have to pre-approve a consultation for an oral appliance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthotics to be provided by out of network provider.You asked the Plan to pre-approve diabetic shoes, inserts and toe filler. You say that you do not want to use a different provider.The Plan denied your request. The Plan says there are contracted providers near you that can provide the orthotics.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 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. 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 orthotics to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 15, 2019 by out of network provide.You asked the Plan to pay for outpatient lab work. You say that this was a continuation of a routine examination from referring physician.The Plan denied your request. The Plan says no prior authorization was 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 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.. The referring provider is also out-of-network. 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 medical services provided on May 15, 2019 by out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99233) provided August 19, 2019 to August 20, 2019.You asked the Plan to pay for the physicians services. You say that the service was medically necessary and properly billed.The Plan denied your request. The Plan says the services should be billed to original Medicare as the enrollee had elected their Hospice benefit at the time services were provided.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 physician services (99233) provided August 19, 2019 to August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 17, 2019.
You asked the Plan to pay for drug test. You say that this service was deemed medically necessary for treatment of the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not show that 22 or more drug classes were tested to support the billing of code G0483.
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 G0483 is drug tests, definitive; qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug classes, including metabolites if performed. We asked our 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 drug test. Our reviewer says that the documentation submitted does not support the billing of code G0483. Our physician reviewer found the record does not contain evidence that definitive drug testing was performed on 22 or more drug classes. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 17, 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 IRF care is medically necessary and the preferred next step in the enrollee's treatment plan. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF 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 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. Our physician reviewer found that ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. Our physician reviewer found that the enrollee is mostly standby assist for functional transfers and activities of daily living. Our physician reviewer found that 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 medical services provided to the enrollee by an out-of-network provider on July 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 for the medical services provided to the enrollee by an out-of-network provider on July 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued outpatient physical therapy.You asked the Plan to pre-approve physical therapy. You say that you need physical therapy but are unable to perform the same physical therapy services at home.The Plan denied your request. The Plan says the denial of authorization for physical therapy is correct.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 physical therapy. 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 the requested therapy is generally accepted as a specific and effective therapy for your condition. However, in this case there is no indication that prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication that residual deficits could not be addressed by a home exercise program. Therefore, the requested physical therapy is 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 physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve continued outpatient physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 50mg Losarton Potassium Tablets.
You asked the Plan to pre-approve the Losarton Potassium. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says drug coverage under your medical only policy is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 50mg Losarton Potassium Tablets.
Benefits for the Losarton Potassium 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99239) provided on August 9, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was enrolled in a federal hospice program.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 date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the services (CPT 99239) provided on August 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received from June 23, 2019, to June 25, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $90 copayment for emergency care. Review of the file shows that you were provided emergency care from June 23, 2019, to June 25, 2019. You have been asked to pay a $90 copayment for the services. The services falls within the emergency 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 emergency care you received from June 23, 2019, to June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120) to be provided. You asked the Plan to pre-approve complete lower denture. You say that if they take out the teeth that are hurting there will be a gap in your mouth and the teeth are in the front.The Plan denied your request. The Plan says this request exceeds the 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. This service is allowed once every 5 years. Records show you had this service February 10, 2015. This service will not be available until after February 10, 2020.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 complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for(CPT Code A4253), (CPT Code A4235), (CPT Code A4256) and (CPT Code A4259) provided to the enrollee on July 23, 2019.You asked the Plan to pay for the DME. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.Therefore, we decided that the Plan does not have to pay for(CPT Code A4253), (CPT Code A4235), (CPT Code A4256) and (CPT Code A4259) provided to the enrollee on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full mouth debridement (code D4355).
You asked the Plan to pre-approve the full mouth debridement. You say that you need the deep cleaning
request to be approved. The Plan denied your request. The Plan says this service is not a covered benefit.
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 a full
mouth debridement (code D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (code D5213) and a
mandibular partial denture (code D5214).
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. The Plan denied your
request. The Plan says these services are not covered 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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
maxillary partial denture (code D5213) and a mandibular partial denture (code D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure.You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee had 90% improvement in pain following the diagnostic injection.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure has not been found to be safe and helpful for the treatment of the enrollee's pain.The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered when dual medial branch blocks provide greater than 80% relief of primary pain.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 radiofrequency ablation. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested radiofrequency ablation. Our physician reviewer found Medicare rules require dual diagnostic medial branch blocks, however only 1 set of diagnostic blocks have been performed. Therefore, the requested procedure is not medically reasonable or necessary 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 radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain pontic and endodontic therapy.
You asked the Plan to pre-approve the porcelain pontic and endodontic therapy. You say that the enrollee has an infection and it is causing them headaches. The Plan denied your request. The Plan says these services are not covered by Medicare or Medicare Assured.
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 enrollee's contract also clearly states that root canals are not covered services. Therefore, we decided that the Plan does not have to pre-approve a porcelain pontic and endodontic therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve the massage therapy. You say that you had this covered in the past and it was very helpful in reducing your back pain and allowing you to be more active. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therapeutic massage is only covered when provided by physical or occupational therapists as part of a covered plan of care. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services you
received on August 1, 2019.
You asked the Plan to waive the copayment. You say that this is covered by Medicare. The Plan denied your
request. The Plan says you are responsible for the copayment.
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 $250
copayment for outpatient surgery services provided in an outpatient hospital.
Review of the file shows that you were provided outpatient surgery services on August 1, 2019. You have been
asked to pay a $250 copayment for the services. The services falls within the outpatient surgery 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 outpatient surgery services you received on
August 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (70450, 73030) provided January 16, 2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claims submitted were duplicates of claims already paid.
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 70450 and 73030 are not supported in the medical record. Specifically, claim for code 70450 is a duplicate of claim which has been paid. Claim is a duplicate of another claim which was already paid. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for Radiology services (70450, 73030) provided January 16, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 6, 2018 through April 15, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 6, 2018 through April 15, 2018.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.