Persius/hicric huggingface dataset:
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 physical therapy and nursing services the enrollee requires 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 thoracic spine surgery for cord compression. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 the office visit provided on March 2, 2021, by an OON provider.
You asked the Plan to pay for the OON services. You say that you were not aware authorization was required. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit provided on March 2, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950) and the provisional crown (D2799) for tooth # 12.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that provisional crown is not listed as a covered service either.
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 core build up and provisional crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core build up (D2950) and the provisional crown (D2799) for tooth # 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on February 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 had network providers available
who could have provided the service 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
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by
the out-of-network (OON) provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 22, 2021.
You asked the Plan to pay for the 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 had network providers available who could have provided 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 services provided by an out-of-network provider on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 7, 2020 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON services. You say that you are a participating provider. The Plan denied
your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 office visit provided on October 7, 2020 by an out-of-network (OON)
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia procedure provided on January 28, 2021.
You asked the Plan to pay for post anesthesia nursing care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this code should not be billed by an anesthesia practitioner.
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 99199 is Unlisted special service, procedure or report. We find that CPT code 99199 cannot be paid as billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of post anesthesia nursing care have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia procedure provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84999) provided on July 1, 2020.
You asked the Plan to pay for laboratory services. You say that this was billed correctly. The Plan denied your request. The Plan says a description of what this code was used to report was not included on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
When billing for unlisted laboratory tests using a Not Otherwise Classified (NOC) code, field 19 on the claim must include the specific name of the laboratory test(s) and/or a short descriptor of the test(s). In this case, the CPT Code Manual definition of code 84999 is unlisted chemistry procedure. We find that CPT code 84999 is not supported in the medical record. Specifically, the specific name of the laboratory tests or a short descriptor of the tests that were billed with this code was not included on the claim. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (84999) provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (90999) provided from November 2, 2020, to November 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that all claims using HCPCS code 90999 should be coded with the appropriate G modifier.
We looked at the file and Medicare rules. In this case, code 90999 was billed without using the appropriate G modifier. 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 the services (90999) provided from November 2, 2020, to November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 RFA to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac joint pain. The review has determined that the requested radiofrequency ablation of the SI joint is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for tooth #'s 4 to 6 to replace tooth #5.
You asked the Plan to pre-approve the bridge. You say that a bridge was done in 1995. You say that there is
visible decay on the x-ray and a new bridge is necessary. The Plan denied your request. The Plan says the
service is not a covered benefit for a posterior tooth.
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, a fixed bridge is only allowed for
permanent anterior teeth. Tooth #5 is considered a posterior tooth, which is not covered. Therefore, we decided
that the Plan does not have to pre-approve a bridge for tooth #'s 4 to 6 to replace tooth #5.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle biopsy provided on April 8, 2021.
You asked the Plan to waive the copayment for the fine needle biopsy. You say that the seroma occurred as a result of surgery on March 29, 2021. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $40 copayment for each specialist's office visit.
You have been asked to pay a $40 copayment for the fine needle biopsy. The fine needle biopsy falls within the "Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers" benefit category. The record shows the fine needle biopsy is considered a surgical procedure. 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 a fine needle biopsy provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the hips (73521), transportation of portable x-ray equipment (R0070), and the set-up of portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on March 16, 2021.
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 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 had network providers available who could have provided 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 x-ray exam of the hips (73521), transportation of portable x-ray equipment (R0070), and the set-up of portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nebulizer with supplies to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve nebulizer and supplies. You say that you need a rural exception to use this supplier. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with the Plan and these items can be obtained from an in-network supplier.
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 nebulizer with supplies to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 member does not have complex nursing and medical management needs requiring a resource intensive inpatient hospital 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 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 sepsis, urinary tract infection, and a supracondylar fracture 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your back, feet and legs hurt. The Plan denied
your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services provided on April 8, 2021.
You asked the Plan to waive the deductible for podiatry services. You say that you cannot afford the charges and feel that the services do not warrant such a high cost-sharing amount. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for podiatry services. You received podiatry services on April 8, 2021. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $103.67.
The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for podiatry services. This cost sharing is a contractual obligation that had not been met at the time podiatry services was received on April 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services provided on April 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test is not medically necessary, and the enrollee does not meet the coverage indications.
The Plan follows Medicare rules. Medicare rules state that cardiovascular nuclear medicine testing may be covered under certain conditions. 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 myocardial perfusion imaging. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested testing. Our physician reviewer found the enrollee has a history of fatigue and poor sleep. She is not complaining of chest pain or associated symptoms that indicate heart disease. She does not have a history of coronary artery disease. She has a history of smoking and dyslipidemia, and she had poor exercise tolerance on her recent stress test which showed normal heart function. The enrollee does not meet the coverage indications for this testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.