Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea repeat medial branch block (MBB).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a repeat MBB 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 not medically necessary. Our physician reviewer found the submitted records show that you have chronic back pain. You have tried physical therapy, pain relief medications, and ice and heat. You had a set of diagnostic MBBs but there is no documentation in the records of the effectiveness of this first set of injections. It is necessary to assess the effectiveness of the first set of diagnostic blocks before performing a second; therefore, the requested services are not reasonable or 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 not been met.Therefore, we decided that the Plan does not have to pre-approvea repeat medial branch block (MBB).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe genetic testing provided on May 15, 2020.You asked the Plan to waive the coinsurance forthe genetic testing. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received genetic testing on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.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 20% coinsurance for genetic testing. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received genetic testing on May 15, 2020. You have been asked to pay a 20% coinsurance for the genetic testing, totaling $152. The genetic testing 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 coinsurance forthe genetic testing provided on May 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide additional physical therapy visits.
You asked the Plan to provide additional physical therapy visits. You say that you need additional physical
therapy. The Plan denied your request. The Plan says continued physical therapy visits are not reasonable and
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 provide additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally
accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy for
this condition and the documentation does not indicate that the patient's functional level requires the unique
skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely
and effectively performed only by a therapist, or under the supervision of a therapist. The patient is
participating in a home exercise program. The requested services are not part of a maintenance program, and
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to provide additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2950, D2740, D5225, D5226) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered 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 Plandoes not haveto pre-approvedental services (D2950, D2740, D5225, D5226) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full fora dental crown (D2740) provided September 18, 2020.You asked the Plan to pay in full forthe dental services. You say that this service should be covered.The Plan denied your request. The Plan says there is a coinsurance for dental services.Medicare generally doesnot 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 plan has already paid its portion. The Evidence of Coverage clearly states there is a 50% coinsurance on major dental procedures.Therefore, we decided that the Plan does not have to pay in full fora dental crown (D2740) provided September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the therapy services rendered could be delivered in another setting such as a skilled nursing facility.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur fracture. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from theintensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXtandi 40mg tablets.You asked the Plan to pre-approveXtandi. You say that Xtandi is medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by MedicarePart B.Therefore, we decided that the Plan does not have to pre-approveXtandi 40mg tablets.Benefits for Xtandimay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF servicesfrom October 1, 2019, through December 31, 2019.You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says prior authorization was not on file for the member to have skilled nursing services rendered out ofnetwork. Services must be provided by providers in our network in order to be covered unless they are urgent care, emergency care, or out of area renal dialysis.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 did not pre-approve the SNF services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plandoes not have to pay forSNF services providedfrom October 1, 2019, through December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlab services (80051, 80061) provided September 24, 2020.You asked the Plan to waive the copayment forthe lab services. You say that the copayment shoul be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab 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 forlab services (80051, 80061) provided September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge day management (99239) provided on September 5, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not payable as the claim was submitted untimely.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 this service was not filed until October 1, 2020. 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 forthe hospital discharge day management (99239) provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea titanium frame, color anodize package, and black seat pouch.You asked the Plan to pre-approvethese 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. Medicare rules say that a titanium frame is included in code K0005 and seat back cushion codes are all-inclusive under other codes. The rules say that items that do not serve a purpose that is primarily in nature are not covered. The services at issue are a titanium frame, black seat pouch, and color anodize package. The titanium frame is already included in the approved K0005 wheelchair frame and is not separately covered. The black seat pouch is already included in the approved services and cannot be separately requested under code K0108. The color anodize package is not covered because it does not serve a purpose that is primarily medical in nature.  Therefore, we decided that the Plan does not have to pre-approvea titanium frame, color anodize package, and black seat pouch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D4341) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered under the benefit package.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 benefitin excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D4341) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided August 1, 2020.
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied
your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
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. There is no itemized shipping receipt and the medical records
provided show no established relationship between the patient and the ordering physician. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for an orthosis (L0650) provided August 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlead wires for a TENS unit (A4557) provided September 9, 2020.You asked the Plan to pay forthe lead wires. You say that the lead wires were medically necessary.The Plan denied your request. The Plan says the unit was purchased within the past 12 months. New wires are not covered.The Plan must follow Medicare rules.Medicare rules say that replacement of lead wires more often than every 12 months would rarely be reasonable and necessary.We looked at the file and Medicare rules. The unit was purchased within the previous 12 months. No medical records were provided to support the need for replacement wires. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met.Therefore, we decided that the Plan does not have to pay forlead wires for a TENS unit (A4557) provided September 9, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the therapy required for the member is not therapy that is uniquely provided in an IRF.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The patient's medical status does not require intensive physician or nursing supervision in an IRF currently. The 1/28/21 document noted the patient is still on Lasix IV twice daily and patient still having episodes of desaturations. It appears the patient still is not medically stable to transfer to any level rehabilitation program yet. While the patient may benefit and participate in multiple therapies the patient's functional level does not appear to be able to tolerate therapy on an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gym membership services provided from January 1, 2019, to December 1, 2019.You asked the Plan to pay forthe gym membership services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says you are not eligible for reimbursement as the Plan showed no enrollment was made with any fitness center.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only if you enroll in one of the three Silver&Fit fitness programs each month.The Plan's rules for coverage of gym benefits have not been met because you did not enroll with any fitness center.Therefore, we decided that the Plan does not have to pay forthe gym membership services provided from January 1, 2019, to December 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 1, 2020.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are 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. ThePlan did not pre-approve the servicesat 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 physician's services provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visit (99214) provided September 17, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you were directed by your surgeon to get your exam and post cataract glasses at this provider. The service should have been billed under your vision care not your health care.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $35 copayment for each specialist visit.You have been asked to pay $35 copayment for the office visit. the office visit falls within the Physician/Practitioner services, including doctor's office visits 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 copayment forthe outpatient office visit (99214) provided September 17, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea folding power wheelchair (K0898).You asked the Plan to pre-approvea folding power wheelchair. You say that the power wheelchair you were loaned while your power wheelchair is being repairedis too wide.The Plan denied your request. The Plan says your current power wheelchair meets your needs.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as a folding power wheelchair.Therefore, we decided that the Plan does not have to pre-approvea folding power wheelchair (K0898).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveright S1-S2 lateral branch blocks for the enrollee.You asked the Planto pre-approvethe blocks. You say that this is medically necessary to assess for radiofrequency ablation.The Plandenied your request. The Plansaysthis is 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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. The review has determined that the requested services at issue 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 the blocks have not been met.Therefore, we decided that the Plandoes not haveto pre-approveright S1-S2 lateral branch blocks for the enrollee.