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

We decided that the Plan does not have to pay for the physical therapy services provided to the enrollee on December 20, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says Original Medicare is responsible for payment of services.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the physical therapy services provided to the enrollee on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical coverage of the sinus augmentation to be provided along with dental implants and related sedation.You asked the Plan to pre-approve medical coverage of the sinus augmentation. You say that the sinus repair is medically necessary.The Plan denied your request. The Plan says this procedure is not covered by Medicare. This procedure is done in preparation for dental implants that are not a covered service by Medicare.Medicare generally does not cover dental services. However, Medicare does cover services that are reasonable and necessary to treat a medical condition. Your plan also covers up to $5000 per year toward dental services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules to determine if the Plan was correct in denying the request to pre-approve medical coverage for the sinus augmentation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation regarding the status of your maxillary bone and sinus is extremely limited. Without a computed tomography scan, we do not know the health of the sinus cavity. Our reviewer found that the note by the implant surgeon mentions "atrophy" on the x-ray. There is no mention of disease process of the maxillary sinus or maxilla due to the atrophy. Therefore, it does not appear there is a medical condition that warrants treatment. This procedure would not be required to treat a medical condition in the absence of the requested dental care. Our physician reviewer also found that the procedure requested is in support of care/treatment/replacement of teeth and supporting structures of the teeth. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the rules for coverage of the sinus augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve medical coverage of the sinus augmentation to be provided along with dental implants and related sedation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 26, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair accessory(K0856), for the enrollee.You asked the Plan to pre-approvethe items. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the durable medical equipment is not 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 items. Our physician reviewer found the patient has a personal mobility deficit but the documentation. She is independent with safety risks in participation in MRADLs. Her mobility deficit can be helped by the use of a walker per a February 3, 2020 DME evaluation. She is unable to safely operate a PMD per documentation due to a seizure disorder. The medical records do not meet the requirements of Medicare's Local Coverage Determination (LCD):Power Mobility Devices (L33789).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 items have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair accessory (K0856), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage services provided on September 3, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
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 10061 is Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. 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 provided. Our reviewer says that the medical records provided do not include documentation that states the incision and drainage procedure that was performed was complicated or multiple. Therefore this service cannot be verified. 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for incision and drainage services provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the limited oral evaluation (D0140) provided on December 18, 2019 by an out of network provider.
You asked the Plan to reimburse the full amount for the dental services. You say that you were recommended by the plan to receive dental services from this dentist. You also say that you should be reimbursed the full amount of $243 that you paid for these services since you were directed by a plan representative. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says when you receive dental service out of network, you may pay more. The Plan also says the specific provider you were recommended and the specific provider you received services from were different dentists.
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 oral exams are a covered service, you may pay more when you receive this service out of network. The record shows that the Plan already reimbursed the allowed amount of $38 for the oral exam that you received out of network. Therefore, we decided that the Plan does not have to reimburse the full amount for the limited oral evaluation (D0140) provided on December 18, 2019 by an out of network provider.
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 needs wound care, rehab therapy, and daily physician management.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the present acute care facility, and still requires acute services.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 physician reviewer found that the enrollee is currently undergoing treatmentat an acute care hospital (ACH) for lower extremity cellulitis complicated by heavily bleeding wounds. The enrollee has undergone wound debridement and continues to receive wound care. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicarerules. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 sessions of physical therapy.You asked the Plan to pre-approve the 4 physical therapy sessions. You say that the enrollee is getting worse without physical therapy.The Plan denied your request. The Plan says the number of visits being requested are not medically 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 pre-approve the 4 physical therapy sessions. 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 physical therapy services requested are not accepted to be specific and effective treatment for the enrollee's condition as the enrollee has had extensive prior physical therapy and her functional level no longer requires ongoing skilled physical therapy. The services are not at such a level of complexity and sophistication, nor are the conditions of the enrollee, that they are required to be performed only by a therapist, or under the supervision of a therapist in order to be safe and effective. The skills of a therapist are not needed to treat the illness or injury. The enrollee should be able to transition to an independent home exercise program at this point. 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 4 physical therapy sessions have not been met.Therefore, we decided that the Plan does not have to pre-approve4 sessions of physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019.
You asked the Plan to pay for the services provided. You say that the enrollee's wife's coverage is secondary. The Plan denied your request. The Plan says it is the provider's responsibility to bill the primary health plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has direct the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve the gloves. You say that this should not have been denied, because you are
allergic to a lot of things, as your skin is sensitive, and you can catch diseases easily. The Plan denied your
request. The Plan says this is not a covered benefit.
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. Additionally, it is
considered hygienic equipment, which is not a covered benefit. Therefore, we decided that the Plan does not
have to pre-approve non-sterile gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided on January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision care services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 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 vision care services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forvision care services provided on January 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forvision care services. You say that these services were medically necessary. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.Medicare rules say that plans can requireenrollees 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 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 forvision care services provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA of the coronary arteries.
You asked the Plan to pre-approve the imaging. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a CT angiography is covered for the above indications. 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 imaging. Our reviewer says that the requested imaging is not medically reasonable and necessary. Our physician reviewer found that based on the records, the enrollee has coronary risk, but no symptoms or objective findings suggestive of coronary ischemia. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning and calcium scoring. Treatment change or addition based on the results of screening with coronary CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based on a combination of standard risk factor profiling and basic lipid analysis. Coverage criteria are not met since there are no documented covered indications for the procedure and the test is not covered for screening purposes. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve CTA of the coronary arteries.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. You asked the Plan to pre-approve the LTACH services. You say that that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary. All services that would be provided in the LTACH are being provided in the current acute care setting. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom ankle-foot orthosis for the enrollee.
You asked the Plan to pre-approve the orthosis. The Plan denied your request. The Plan says that there is no documentation in the treating physician's records to support the medical necessity of custom fabricated rather than a prefabricated orthosis.
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 orthosis. Our reviewer says that a custom ankle-foot orthosis is not considered medically reasonable and necessary in this case. There is no documentation by the physician of any neurological deficit at the time leading to the prescription of the AFO. Also there is no knee exam to document the Knee instability/Laxity described in the CPO's note. Another discrepancy is that there is no mention of CVA in the in the physician's note which was found in the CPO's note. The CPO's notes are confusing in that the note on 2/4 stated Right foot drop and cast impression taken for the right foot and the weakness in the letter was all about the left ankle. Our physician reviewer found that the enrollee does not meet the coverage criteria based on the lack of appropriate and accurate documentation of the need for an AFO or a custom fabricated AFO. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom ankle-foot orthosis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care physician (PCP) services rendered on December 5, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were a preventive visit and should have no copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for primary care office visit with other in-network doctors.
Review of the file shows that you received primary care office visit services on December 5, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the primary care office visit with other in-network doctors 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 for the primary care physician (PCP) services rendered on December 5, 2019.