Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
need to take part in 3 hours of therapy a day, or need an intensive team approach for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee was admitted to the hospital with an acute myocardial infarction necessitating a cardiac 
catheterization. He has stabilized medically without any post-procedural complications. The enrollee does not 
have any parental medications, complex wound care or care needed for a feeding tube. There is no indication 
that he would require rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status. He is ambulating up to 50 feet with minimal assistance, and 
requires minimal assistance for transfers and mobility and most activities of daily living. He is near his prior 
level of function. Therefore, the requested IRF services are not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a joint stabilizer (L2385) provided to the enrollee on April 5, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 

The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, 
L2397) with a joint stabilizer (L2385) provided to the enrollee on April 5, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (CPT Code J7325). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this requirement encourages the enrollee to try the Plan's preferred drug(s), which 
is/ are just as effective: Monovisc and Orthovisc. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, 
as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not 
approved, as step criteria have not been met. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (CPT Code J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service so that your dentures 
will fit in your mouth. You also say that you will be in agony if you cannot get this service approved and you 
try to get dentures. The Plan denied your request. The Plan says removal of torus mandibularis is not listed as a 
covered service. The Plan also says any service not listed is not covered. 
 
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. Additionally, the Evidence of Coverage clearly states that any service 
not listed is not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of torus 
mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance, occlusal adjustment, and amalgam provided on July 23, 2020, and September 2, 2020.You asked the Plan to pay forthe periodontal maintenance, occlusal adjustment, and amalgam. You say that you would like these claims to be reconsidered.The Plan denied your request. The Plan says periodontal maintenance and occlusal adjustment are not covered benefits. The Plan also says that your benefits for the amalgam restoration had been satisfied and the frequency limitation had been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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, periodontal maintenance and occlusal adjustment are not among those covered under this benefit. The Plan contract also says that you are limited to up to 1 amalgam or composite filling per year. The record shows that you received a resin-based composite on July 14, 2020, and your amalgam or composite filling benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance, occlusal adjustment, and amalgam provided on July 23, 2020, and September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the lab services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dermatology services provided on December 3, 2019 by an out of network provider.You asked the Plan to pay forthe dermatology services. You say that the receptionist led you to believe that the provider was in network.The Plan denied your request. The Plan says you did not request prior authorization for the out of network services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe dermatology services provided on December 3, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have towaive the copayments forthe diagnostic mammogram, ultrasounds and diagnostic digital breast tomosynthesis provided on September 9, 2020.You asked the Plan to waive the copayments forthe diagnostic mammogram, ultrasounds and diagnostic digital breast tomosynthesis. You say that you never had to pay copays before.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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 copayment for Outpatient Diagnostic Tests. You have been asked to pay $20 copayment for each of the diagnostic mammogram, ultrasounds and diagnostic digital breast tomosynthesis. The diagnostic mammogram, ultrasounds and diagnostic digital breast tomosynthesis falls 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 forthe diagnostic mammogram, ultrasounds and diagnostic digital breast tomosynthesis provided on September 9, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiography (CPT Code 93306) provided on August 27, 2020.You asked the Plan to waive the copayment forthe echocardiography. You say that you never had a copay for this amount.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an echocardiography on August 27, 2020. You were asked to pay a $125 copayment for the radiological diagnostic service. The health plan contract says that enrollees must pay a $125 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 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 echocardiography (CPT Code 93306) provided on August 27, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe services (CPT 69210) provided on August 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the cerumen removal is included in the evaluation and management service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coding 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 services. Our reviewer says that the use of CPT code 69210 is supported by the records provided. Our coding reviewer found that for cerumen removal that is not impacted, this procedure would be reported with the proper Evaluation and Management code. In this case, the provider documents ears were completely occluded with firm/hard cerumen, and ENT instruments were used to extract cerumen. Therefore, this procedure should be reported separately.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pay forthe services (CPT 69210) provided on August 17, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram (93000) provided on April 9, 2020.You asked the Plan to pay forthe electrocardiogram. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is no additional documentation supportingan additional study.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Specifically, the record does not indicate that this provider rendered an electrocardiogram on the billed date of service.Therefore, we decided that the Plan does not have to pay forthe electrocardiogram (93000) provided on April 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing
or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service
criteria for an inpatient basis in a 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 SNF for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forinfrared therapy (CPT Code 97026) provided on July 24, 2020.You asked the Plan to pay forthe service. You say that the service is necessary and the claim should be paid.The Plandenied your request. The Plan says infrared therapy is considered not reasonable and necessary.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theservice have not been met. For code 97026 Infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage.Therefore, we decided that the Plan does not have to pay forinfrared therapy (CPT Code 97026) provided onJuly 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for the acute inpatient hospital care provided from
January 21, 2021, through January 22, 2021.
You asked the Plan to pre-approve for acute inpatient hospital care. You say that the stay is medically
necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve for acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the review has determined that the record did not show that at the time of
inpatient admission the admitting physician reasonably expected that your necessary hospital care (including
earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file,
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient
hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve for the acute
inpatient hospital care provided from January 21, 2021, through January 22, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your request. The Plan says that the guidelines support up to three PET/CT fusion scans to plan subsequent treatment of this oncologic condition. The Plan states the clinical information provided shows that the requested study would exceed this allowed limit and further imaging with PET/CT is not supported.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer found there is a suspicious area that needs to be characterized with PET/CT scan that will determine therapy of biopsy or XRT. Due to the need for this data for important patient management decisions, the test is indicated. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance on July 25, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance on July 25, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
August 13, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the
charges because you only paid $50 in the past. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on August 13, 2020. The allowed amount is $947.05 and 20% of that is
$189.41.
You have been asked to pay the total coinsurance amount of $189.41 for a Medicare Part B drug. A Medicare
Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to payformiscellaneous DME supply or item, face masks (A9999) provided on August 6, 2020 by a non-Medicare certified provider.You asked the Plan to pay forface masks. You say that you have issues with the claim being denied for services that should be covered.The Plan denied your request. The Plan says this item is not a covered DME item and the provider is not a participating Medicare provider.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay formiscellaneous DME supply or item, face masks (A9999) provided on August 6, 2020 by a non-Medicare certified provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 30, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.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 forthe medical services provided on June 30, 2020, by an out-of-network provider.