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

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is a threat to society if not approved for inpatient stay. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved and is no longer a threat to himself or others.
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 hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. The patient is not shown to be a danger to herself or others. She is not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This patient was not showing any aggressive behaviors or any treatment required for acute threats of safety. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy rendered on October 20, 2020.
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 procedure code 97140 is not supported.
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 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
We find that CPT code 97140 is not supported in the medical record. Specifically, there is no documentation of the minimum of at least eight minutes of therapy services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the manual therapy rendered on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET with CT (78815) provided on December 14, 2020.
You asked the Plan to pay for the PET with CT. You say that you would like reconsideration because this claim was coded with the appropriate diagnosis code. The Plan denied your request. The Plan says this claim was not reported with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 78815 is not supported in the record. Specifically, the Medicare Claims Processing
Manual includes a list of appropriate diagnosis codes for the service billed. The diagnosis code billed is not included on that list. Based on this information, we decided that Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the Plan does not have to pay for PET with CT (78815) provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88361 and 88323) provided on September 23, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says insufficient information was provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not
been met. The denial is being upheld due to the provider not submitting the physician/exam notes with supporting documentation that are needed in order to determine the clinical utility of the testing. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88361 and 88323) provided on September 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (CPT code(s): 97110 and 97140) and a physical therapy evaluation (CPT Code 97161) provided on December 1, 2020.
You asked the Plan to waive the copayment for the physical therapy services. You say that you are appealing your cost-share responsibility for the services you received. 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 physical therapy services (CPT code(s): 97110 and 97140) and a physical therapy evaluation (CPT Code 97161) on December 1, 2020. You were asked to pay a $35 copayment per therapy service. Therefore, you are responsible for a $70 copayment for the physical therapy services. 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 physical therapy services (CPT code(s): 97110 and 97140) and a physical therapy evaluation (CPT Code 97161) provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364) and problem focused limited oral evaluation (D0140).
You asked the Plan to pre-approve the cone beam CT capture and interpretation and problem focused limited oral evaluation. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says cone beam CT capture and interpretation is not covered under your benefit package. The plan also says that the problem focused limited oral evaluation exceeds the maximum count allowed per period.
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, cone beam CT capture and interpretation (D0364) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 5, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364) and problem focused limited oral evaluation (D0140).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services provided on February 15, 2021.
You asked the Plan to waive the copayment for the surgical services. You say that this was only made necessary by an unnecessary prescription. 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 the surgical services on February 15, 2021. You were asked to pay a $245 copayment for the surgical services. Your 2021 EOC states that enrollees must pay a $245 copayment for surgical services at an ambulatory surgical center. 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 surgical services provided on February 15, 2021.
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 on November 20, 2020, by a non-participating provider.
You asked the Plan to pay for the medical services. You say that the services were necessary. The Plan denied
your request. The Plan says this provider is a non-participating provider, 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 on November 20, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in bath purchased on November 12, 2020.
You asked the Plan to pay for a walk-in bath. You say that without a walk-in shower or tub you will have to search for some kind of assisted living as it is totally impossible to bathe without full time assistance. The Plan denied your request. The Plan says a walk-in bath is not covered by Medicare or the health plan.
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 for a walk-in bath purchased on November 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an
OON provider.
You asked the Plan to pre-approve the OON outpatient mental health services. You say that you are a
registered provider with Medicaid and that the enrollee can benefit from services that you are able to provide
for her diagnosis of adjustment disorder. The Plan denied your request. The Plan says the enrollee does not
have special needs that require the use of an OON provider. The Plan says that there are network providers near
the enrollee that can provide the same services being requested from the OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
outpatient mental health services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) (CPT code 43644) and laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components (CPT Code 43774), for the enrollee.
You asked the Plan to pre-approve the surgical services. You say that the only way to correct the mega-esophagus is to remove the lap band. You state conversion to a gastric bypass will treat both comorbidities and relieve the obstruction causing the esophageal dilation and stasis. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 the surgical services have not been met. Review of the file shows that the enrollee has laparoscopic gastric banding in 2010. Repeat bariatric surgery is generally not reasonable or necessary per LCD.
Therefore, we decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) (CPT code 43644) and laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components (CPT Code 43774), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve complex cataract removal.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that complex cataract removal is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are medically necessary.

Our physician reviewer found the enrollee has age related 3+ nuclear sclerotic and cortical cataracts of both eyes causing impairment of visual function, resulting in specific activity limitations that are not correctable with a change in glasses or contact lenses. The Medicare criteria state that complex cataract surgery differentiates the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations including the presence of a disease state that produces lens support structures that are abnormally weak or absent.

This requires the need to support the lens implant with permanent intraocular sutures and/or a capsular support ring (approved by the FDA) may be necessary to allow placement of an intraocular lens. The enrollee meets the criteria for coverage and the requested surgery is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve complex cataract removal.

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 the magnetic resonance imaging, chest (71550).

You asked the Plan to pre-approve the MRI. You say that you've had pain for a few years and your new PCP has put you through many tests and x-rays and the last resort is to have an MRI to see if they can find out where the pain is coming from. The Plan denied your request. The Plan says the records do not support that the enrollee meets the coverage criteria for the requested service.

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. 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 do not provide reasoning for the medical necessity of an MRI and what it would be evaluating in this enrollee with chronic chest and abdominal pain issues. Given that it is unknown what is being investigated with this imaging modality, it would not be considered medically appropriate 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, chest (71550).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel-One.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the step therapy requirement is not met.

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. The Plan states that Gel-One is not covered because you have not tried and
failed the required step therapy drugs, Orthovisc and Monovisc. However, the Plan has not provided any
medical records to support that you have not tried and failed the required drugs. Therefore, we decided that the
Plan has to pre-approve Gel-One.

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 the services provided by an out-of-network provider from November 3, 2020, to December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider from November 3, 2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on December 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on December 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on November 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services you received on November 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network specialist.
You asked the Plan to pre-approve the out-of-network office visit. The Plan denied your request. The Plan says in-network providers are available.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 out-of-network office visit. Our reviewer says that there is no need for an out-of-network referral. Our physician reviewer found that your care can safely be managed in-network.
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 out-of-network office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit with an out-of-network specialist.