Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (CPT code 72197) and MRI abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183), for the enrollee.

You asked the Plan to pre-approve the MRIs. You say that the services are necessary. The Plan denied your request. The Plan says they did not receive physical exam results that show a reason this study is needed. The Plan states the records indicate the enrollee had computed tomography (CT) and an upper and lower scope as well, the enrollee's records did not include a detailed history that shows this study is needed and the Plan needs to see results of prior picture studies such as x-ray or ultrasound (picture study using sound waves) that show a reason this request is needed.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRIs. Our physician reviewer found the requested imaging study is not medically necessary and reasonable. The documentation indicates that the enrollee has or may have a bowel obstruction. There are no physical exam results that show a reason the study is needed. The records did not include a detailed history that shows why this study is needed. Results of prior imaging studies have not been provided. Guidelines support follow-up imaging with CT or MRI enteroclysis/enterography when the etiology or level of suspected intermittent or low-grade small bowel obstruction remains undetermined after an initial CT abdomen and pelvis. The clinical information provided does not meet these criteria and, therefore, the request is not indicated at this time. The review has determined that the requested MRI 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 the MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (CPT code 72197) and MRI abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) provided December 2, 2020.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says that the documentation is missing
required criteria.

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. In this case, the Plan has failed to substantiate what necessary criteria the
provider is missing. We found that the provider is licensed in the state where the services were performed and
is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the
services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837)
provided December 2, 2020.

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: 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 SNF is the best option for your recovery. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90832) provided December 4, 2020.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that the documentation is missing the required criteria.

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. In this case, the Plan has failed to substantiate what necessary criteria the provider is missing. We found that the provider is licensed in the state where the services were performed and is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90832) provided December 4, 2020.

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: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth # 10.

You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied your request. The Plan says that the tooth does not have significant breakdown.

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. The Plan covers the dental service when the services are medically necessary and reasonable. 

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 dental service. Our reviewer says that the crown is medically necessary. Our physician reviewer found the provided documentation indicates that tooth # 10 has significant coronal breakdown. Therefore, the reviewer found that the crown for tooth # 10 is medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth # 10.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulator supplies, 2 lead, per month (CPT
code A4595), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the documentation submitted by the provider was from 2019, and there is no
documentation that the enrollee is using it and benefiting from it at this time.

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 DME. Our physician reviewer found there was insufficient documentation describing the enrollee's use of the stimulator and supplies or how effective they were at improving symptoms and function. Therefore, without this supportive information provided, this request for additional stimulator supplies does not meet requirements for coverage 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 the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical stimulator supplies, 2 lead, per month (CPT code A4595), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are doing your best to avoid costs in the upcoming years by being able to manage this at home with the durable medical equipment recommended, Flexitouch system. The Plan denied your request. The Plan says there is insufficient documentation to support the diagnosis of lymphedema. The enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH services. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with hypoxic respiratory failure due to sepsis from pneumonia. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory pathology work provided on November 18, 2020.

You asked the Plan to waive the cost share for the laboratory pathology work. You say that you should not have been billed because the laboratory work was part of your routine colonoscopy. 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. Your contract with the Plan says that there is a $250 deductible that applies towards laboratory pathology work and 20% of the cost for Medicare-covered laboratory services.

The laboratory pathology work you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards laboratory pathology work and 20% of the cost for Medicare-covered laboratory services. The record shows a polyp was removed during the colonoscopy and sent to pathology for testing which makes the laboratory pathology work diagnostic in nature. See chart below.

Date of Service
Service
Allowed Amount
Deductible/
Coinsurance
Member Liability

November 18, 2020
Immunohistochemistry
$150.07
$250
$110.01 - This amount was applied to your deductible which satisfied the total deductible amount.

November 18, 2020
Special stains group 2
$162.18
20%
$32.44

November 18, 2020
Special stains group 1
$225.10
20%
$45.02

November 18, 2020
Tissue exam
$200.09
20%
$40.02

Total
$227.49

This cost sharing is a contractual obligation that had not been met at the time the laboratory pathology work was received on November 18, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory pathology work provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.

You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is 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 pre-approve inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it does not appear that the services in question is reasonably expected or medically necessary to improve your condition as you are not a danger to yourself or others and you do not have any delusions, auditory or visual hallucinations. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Specifically, you could be treated in a less restrictive setting as you are not showing any suicidal or homicidal ideation, auditory or visual hallucinations, and delusions. This means continued inpatient psychiatric hospitalization is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal orthosis (L0457) provided April 9, 2021.

You asked the Plan to pay for the spinal orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the provider and the member.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed 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 pay for the spinal orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a spinal orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 

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 spinal orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the spinal orthosis (L0457) provided April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the removal of impacted earwax (69210) provided on March 11, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the service provided.

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 $30 copayment for each Medicare-covered visit with a specialist. Additionally, you must pay a $150 copayment for Medicare-covered outpatient hospital surgery services.

You have been asked to pay $87.43 which includes a $30 copayment for the Medicare-covered visit with a specialist and the Plan allowed amount of $57.43 for the Medicare-covered outpatient hospital surgery, which is less than the applicable copayment for this service. The removal of impacted earwax 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 copayments for the removal of impacted earwax (69210) provided on March 11, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on December 11, 2020.

You asked the Plan to pay for genetic testing. You say that Medicare covers this testing and the Plan is required to reimburse you no less than the amount that would be paid under original Medicare. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee was not being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on December 11, 2020.

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 an addition amount for the amalgam - two surfaces, primary or permanent (D2150), and the amalgam - one surface, primary or permanent (D2140) received April 1, 2021 received from the out-of-network provider.

You asked the Plan to pay an addition amount for the amalgams. You say that you disagree with how reimbursement was calculated. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 payment is in excess of what is covered under this benefit. The Plan requires 55% coinsurance for amalgams when received from an out-of-network provider. The Plan's allowed amount for D2150 was $83.00. 55% of $83.00 is $46.65. The Plan's allowed amount for D2140 was $68.00. 55% of $68.00 is $37.40. In addition, if you use an out-of-network dentist, your share of the cost may be higher. You are responsible for any amount over and above the Plan's allowed amount for the requested services that may be billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an addition amount for the amalgam - two surfaces, primary or permanent (D2150), and the amalgam - one surface, primary or permanent (D2140) received April 1, 2021 received from the out-of-network provider.