Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 14, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with the correct code.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this service was performed in a home health or hospice setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been
met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.

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 additional accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate three or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength in the right upper extremity supports that you can control any power options through their own individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system (CPT code 22899), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this procedure fills a treatment gap for those enrollees that do not receive adequate relief from traditional conservative methods, and do not have instability to indicate that fusion is appropriate treatment. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding any objective clinical exam findings. Furthermore, the magnetic resonance imaging (MRI) did not demonstrate Modic Type 1 or 2 changes at the requested level of the procedure (L4 and L5). Additionally, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollee's chronic persistent spinal pain. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment in this clinical scenario.
Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept intraosseous nerve ablation system at L4 and L5 (CPT 22899) 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system (CPT code 22899), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided February 13, 2020.

You asked the Plan to pay for subsequent nursing facility care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has been filed past the allowed 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for subsequent nursing facility care was not filed until February 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided February 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the routine transportation services. You say that your request should be categorized as emergency transportation because you are nearly blind and will be completely blind if you are unable to get to the doctors. You say that you have not been to the endocrinologist in almost a year, and that this doctor will not see you if you pass the year mark. You say that you need to go to the dentist to get a new mouth guard. You say that you are severely overweight and that you cannot leave your house without a wheelchair. You say that you do not have anybody with a wheelchair capable vehicle. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine provided on March 29, 2021
You asked the Plan to pay for the Tdap vaccine. You say that you live in your own home, do your own yardwork, and work on your property and equipment. You state you are risk for injury that could lead to tetanus. The Plan denied your request. The Plan says routine tetanus vaccinations are not covered unless there is an injury or laceration.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine provided on March 29, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.

You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the notes do not show that you have any of the conditions listed as criteria for the Group 3 power wheelchair.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity.

The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for these services.
You asked the Plan to pay for out of network outpatient mental health services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 Plan contract also states that outpatient mental health care both in and out of network requires prior authorization.
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 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 outpatient mental health services provided from March 19, 2020, to April 2, 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 hospital outpatient visit rendered on January 6, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. 

We looked at the file and Medicare rules. Billed procedure code G0463 (hospital outpatient clinic visit) has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the hospital outpatient visit rendered on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (PPE) (D1999) provided on June 24, 2020, and December 29, 2020.
You asked the Plan to pay for the PPE. You say that you do not feel you should be responsible for the PPE fee. You had to see the dentist and they understand that they need to take preventative measures due to the pandemic. The Plan denied your request. The Plan says personal protective equipment is not covered under the Plan's supplemental dental 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 pay for the personal protective equipment (PPE) (D1999) provided on June 24, 2020, and December 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan has to pre-approve the 6 physical therapy visits. We decided that the Plan does not
have to pre-approve the 6 skilled nursing visits and the 6 occupational therapy visits.

You asked the Plan to pre-approve the 6 physical therapy visits. You say that the requested services are
medically necessary. The Plan denied your request. The Plan says that the rules for home health services have
not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

We decided that the Plan has to pre-approve 6 physical therapy visits.

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 skilled nursing and the occupational
therapy services. Our reviewer says the requested physical therapy visits are medically necessary. The reviewer
found that it is noted that you were experiencing weakness following a hospitalization. The reviewer found that
a period of physical therapy to see if improvements in strength and endurance can be made is medically
necessary and reasonable.

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 requested physical therapy has been met. Therefore, we decided that the
Plan has to pre-approve 6 physical therapy visits.

We also decided that the Plan does not have to pre-approve the 6 skilled nursing visits and the 6
occupational therapy visits.

Our reviewer says that skilled nursing services and occupational therapy are not medically necessary. Our
physician reviewer found you do not have documented skilled nursing needs. The reviewer found that you do
not have documented skilled occupational therapy needs. The reviewer found that you have the necessary DME
equipment and a family member who can assist as needed. Therefore, the reviewer found that the requested
skilled nursing services and occupational therapy are 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 skilled nursing and the occupational therapy have not been met. Therefore, we
decided that the Plan does not have to pre-approve the 6 skilled nursing visits and the 6 occupational therapy
visits.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.

You asked the Plan to pre-approve the MRI services. You say that the enrollee wants to proceed with surgery and the MRI is needed to rule out significant medial or lateral chondral damage. The Plan denied your request. The Plan says there was no information provided to show that the requested MRI is medically necessary.

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 MRI services. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the enrollee had a one-week history of knee pain without history swelling. Examination was limited by pain and swelling. No treatment had been tried and failed. No re-examination has been performed. 

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 MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiology services provided on January 15, 2021 and January 22, 2021.

You asked the Plan to waive the copayments for the radiology services. You say that you did not expect to get a bill for these services. The Plan denied your request. The Plan says you were charged the copayments 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 $45 copayment per provider, per date of service for Outpatient Diagnostic Tests.

You have been asked to pay a $45 copayment per provider, per date of service, for the radiology services. The radiology services fall within the Outpatient Diagnostic Tests 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 copayments for the radiology services provided on January 15, 2021 and January 22, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for wound care. We decided that the Plan does not have to waive the copayment for wound care.
You asked the Plan to waive the copayment for wound care. You say that you never paid this much before. The Plan says that the correct copayment has been applied.
We decided that the Plan has to reduce the copayment for wound care.
With the evidence that was provided by the Plan, the Plan has overcharged for wound care. Therefore, we decided that the Plan has to reduce the copayment for wound care.
We also decided that the Plan does not have to waive the copayment for wound care.
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 for wound care. Therefore, we decided that the Plan does not have to waive the copayment for wound care.
Date of Service
Copayment
Amount Being Asked to Pay
December 31, 2020
$350
$321.62
January 8, 2021
$350
$321.62
February 4, 2021
$350
$321.62
February 11, 2021
$350
$321.62
February 18, 2021
$350
$341.27
February 25, 2021
$350
$341.27
March 4, 2021
$350
$139.32
Total Amount Being Asked to Pay:
$321.62 + $321.62 + $321.62 +$321.62 + $341.27 + $341.27 + $139.32 = $2,108.34
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: Unfavorable

We decided that the Plan does not have to pay for established patient assisted living visit, typically 40 minutes (CPT code 99336) provided to the enrollee on December 22, 2020.
You asked the Plan to pay for the services. You say that the provider is a hospitalist physician who depends upon the hospital staff to verify eligibility. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for established patient assisted living visit, typically 40 minutes (CPT code 99336) provided to the enrollee on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says as acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage to moving the enrollee from the current hospital to the LTACH.

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. Our physician reviewer found that in this case, the enrollee was admitted after being being assaulted and sustaining a cervical spine injury and neurogenic shock. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied.

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0429) provided on January 18, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not request ambulance transportation, and feel the cost is too high for such a short trip. The Plan denied your request. The Plan says the copayment was 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 $300 copayment for each one-way ambulance transport. You have been asked to pay a $300 copayment for the ambulance transportation. 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 ambulance transportation services (A0425, A0429) provided on January 18, 2021.