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

We decided that the Plan does not have to pre-approve an ultrasound to be provided by the out of network provider.
You asked the Plan to pre-approve an ultrasound. You say that you would like authorization for this ultrasound. The Plan denied your request. The Plan says there are in-network providers available 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 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 an ultrasound to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the
available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. A physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain crown (D2740).
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says that the documentation provided does not support the need for the replacement of the existing crown.
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. We found that the Plan failed to send the correct Evidence of Coverage that pertains to this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore, the Plan has not substantiated their denial of authorization in this case. Therefore, we decided that the Plan has to pre-approve a porcelain crown (D2740).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would benefit from LTACH care.The Plan denied your request. The Plan says the current facility can meet all the enrollee's needs just as well as an 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation, intermittent BiPAP, overnight CPAP, and nebulizer treatments, intravenous antibiotics, intravenous steroids, surveillance laboratory studies, nutritional management, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe sleep study provided on March 14, 2019.You asked the Plan to waive the coinsurance forthe sleep study. You say that you were informed insurance would cover it all. You say that you don't have the money to pay.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for outpatient hospital services. You have been asked to pay $213.81, which is 20% ofthe allowed amount for the sleep study. The allowed amount is $1,069.04 (20% x $1,069.04 = $213.81). The sleep study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been askedto 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 coinsurance forthe sleep studyprovided on March 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 29, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 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 forthe medical services provided to the enrollee by an out-of-network provider on September 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital services provided June 8 to June 15, 2019.You asked the Plan to pay forthe inpatient hospital services. You say that the services were medically necessary.The Plan denied your request. The Plan says the provider failed to provide all medical records necessary to complete a thorough review for prior authorizationThe Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. In this case, the provider failed to furnish the complete medical record to the plan. The plan was unable to determine if the services at issue could be preauthorized. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services havenot been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital services provided June 8 to June 15, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve hammertoe repair (28285).You asked the Plan to pre-approve the hammertoe repair. You say that you wear inserts, have been treated for 6 months and have developed a painful callus. The Plan denied your request. The Plan says that the information sent does not show other treatments that have been tried and does not show how long you have had this problem or how it causes problems in your daily life.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the hammertoe repair. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this particular case, a malformed body member is your fifth digit hammertoe. The procedure recommended, repair of hammertoe, is certainly safe and effective, not mainly for your convenience, not experimental or investigational, and certainly appropriate for what is described as a significant hammertoe right side.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 hammertoe repair have been met. Therefore, we decided that the Plan has to pre-approve hammertoe repair (28285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that it is felt that the enrollee would benefit from care in the IRF.The Plandenied your request. The Plansaysthe enrollee'scurrent level of confusion and medical instability indicate that rehab should be delayed at this time.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 patient is medically too sick and needs care by acute care physicians and not acute IRF PMR physician. IRF admission is not medically appropriate based on her current functional status and medical instability.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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 70450) provided to the enrollee on August 14, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a duplicate claim line.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules.The submitted documentation shows that the services in question were billed on a duplicate claim line to services that were previously paid by the plan for the same provider on the same date of service.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 forthe services (CPT 70450) provided to the enrollee on August 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manipulation of the knee joint (27570).You asked the Plan to pre-approve the knee surgery. You say that you would like reconsideration as this service is medically necessary. The Plan denied your request. The Plan says criteria is not met as the member's knee range of motion is 120 degrees.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 knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records document near normal range of motion.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 knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve manipulation of the knee joint (27570).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe LINX procedure (43284).You asked the Plan to pre-approvethe LINX procedure (43284). You say that the requested LINX procedure is medically necessary.The Plan denied your request. The Plan says the requested LINX procedure is not medically necessary.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 LINX procedure (43284). Our reviewer says that the requested LINX procedure is not medically necessary. Our physician reviewer found the enrollee is with fibromyalgia, hypothyroidism, osteopenia, obstructive sleep apnea, status post C-section, and orthopedic knee procedure. Pertinent to this review, the enrollee has GERD for which implantation of the LINX procedure has been requested regardless of documented charting that she currently takes Nexium 40mg daily which controls her heartburn very well per documentation. However, the enrollee has Barrett's esophagus and solid food dysphagia (to chicken, meat, bread) secondary to esophageal stricture that has required endoscopically-guided dilation on several occasions. The LINX device received FDA premarketing approval effective March 22, 2012. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. This enrollee however has significantly benefited from Nexium. Not only then, in enrollee's setting, should implantation of LINX be approached with caution given her documented complaints of dysphagia, but the safety and efficacy of LINX has not been established in the enrollee's setting of Barrett's esophagus.Neither the LINX implantation surgery, nor the requested hospitalization, meets coverage criteria for the enrollee in this case.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 LINX procedure (43284) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe LINX procedure (43284).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided from November 13, 2018 to November 14, 2018.You asked the Plan to waive the copayment forthe emergency room visit. You say that you do not agree with the copayment because you the ER visit was a result of a colonoscopy. The Plan denied your request. The Plan says you have been charged 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 Planclearly says that you must pay a $80 copayment for Medicare-covered emergency room visits. You have been asked to pay a $80 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room visit.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 forthe emergency room visit provided from November 13, 2018 to November 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99212), application of hot or cold packs (97010), mechanical traction therapy (97012), and electrical stimulation (97014) provided from August 12, 2019 to August 21, 2019.You asked the Plan to pay fora chiropractic office visit, application of hot or cold packs, mechanical traction therapy, and electrical stimulation. You say that these services were necessary to help the enrollee walk.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit(99212), application of hot or cold packs (97010), mechanical traction therapy (97012), and electrical stimulation (97014) provided from August 12, 2019 to August 21, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for outpatient services (74176, 80048, 81001, 85025 and 99283) provided on May 6, 2019.You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the claim submitted is missing an appropriate modifier.The Plan must follow Medicare rules. The rules say that Medicare health plans mustmake reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to substantiate their denial. Therefore, we decided that the Plan has to pay for outpatient services (74176, 80048, 81001, 85025 and 99283) provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.You asked the Plan to pre-approvehome health aide services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.ThePlan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee has skilled therapy or skilled nursing needs. Therefore, the request for home health aide services is not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on October 9, 2019.You asked the Plan to pay forthe dental service. You say that you have a very low income. You say that 6 months ago the Plan covered this service as in network. You say that you thought it would be the same way this time. You also say that you can only pay $25.50.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says there is a 50% cost share when you receive the service out of network.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 and prophylaxis is a covered service, there is a 50% cost share when you receive this service out of network.The record shows that the previous visit on February 5, 2019 with this provider was paid as a one-time exception by the Plan.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on October 9, 2019