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

We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the provider specializes in overweight patients. The Plan denied your request. The Plan says there are participating endocrinologist readily available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve endocrinology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 47361 and CPT 44120) provided to the enrollee on November 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
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 the denied codes is: CPT 47361: Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver CPT 44120: Enterectomy, resection of small intestine 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the provider reported CPT 47361 and CPT 47362. Per NCCI edits, these CPT codes cannot be reported separately for same date of service, and, no modifier is allowed to bypass edit. The provider billed CPT 44120. The operative report does not include enough documentation to support an anastomosis was performed on small intestine to confirm procedure was performed. 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 not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 47361 and CPT 44120) provided to the enrollee on November 23, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the self-administered drugs (A9270).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that self-administered drugs provided in the outpatient hospital setting are not payable under your contractual policy or by Medicare.

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. Specifically, the Plan has not provided information about the self-administered drugs provided to you on this date of service. Therefore, we decided that the Plan has to pay for the self-administered drugs (A9270).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular overdenture.
You asked the Plan to pre-approve overdenture. You say that you need this because without it you have a lot of difficulty eating. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this overdenture is not covered by the Plan's dental benefits.
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 Plan does not have to pre-approve a complete mandibular overdenture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (CPT code 93970), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's doctor has ordered an imaging test for the enrollee's legs (Duplex scan). The Plan states that this test has already been approved and the approval expires on August 25, 2021. The Plan states that another test is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. This test has already been approved and the approval expires on August 25, 2021. Therefore, another test is not medically necessary and cannot be approved. Therefore, we decided that the Plan does not have to pre-approve duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (CPT code 93970), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Trifocal lenses (V2303), anti-reflective coating (V2750), miscellaneous vision service (V2799), and multi-vitamins (A9153).

You asked the Plan to pay for the vision services and lenses. You say that you have not received reimbursement for this claim yet and need the money. The Plan denied your request. The Plan says they have already paid your maximum allowance of $400 for the 2019 Plan year. The additional amount requested exceeds the Plan's supplemental benefit allowance.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $400 per year. You are responsible for any costs that exceed this allowance.

We looked at the file and the Plan's rules. The Plan has indicated that part of your benefit was used to pay for the glasses and the remainder of your $400 allowance was paid out for the services. You are responsible for any costs that exceed the Plan's $400 maximum annual allowance. Therefore, we decided that the Plan does not have to pay for the Trifocal lenses (V2303), anti-reflective coating (V2750), miscellaneous vision service (V2799), and multi-vitamins (A9153).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the scanning computerized ophthalmic diagnostic imaging and internal eye photography provided on September 22, 2020 during an ophthalmology office visit.
You asked the Plan to waive the charges for the diagnostic eye imaging. You say that you were not told by the provider that you would have to pay an extra copayment for the services provided during this visit. You state that you cannot afford this charge with your fixed income. The Plan denied your request. The Plan says your EOC states that there is a $50 copayment for diagnostic procedures and tests.
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 $50 copayment for other diagnostic procedures/tests. You have been asked to pay a $50 copayment for the diagnostic eye imaging. This imaging falls within the other diagnostic procedures/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 charges for the scanning computerized ophthalmic diagnostic imaging and internal eye photography provided on September 22, 2020 during an ophthalmology office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210).

You asked the Plan to pay for the dental service. You say that you needed the extraction to be done. You also
say that you have a heart condition where having an infected tooth would jeopardize your health. The Plan
denied your request. The Plan says surgical extractions are listed under Class 3 Major Services. The Plan also
says that you pay 100% for Class 3 Major Services.

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 surgical extraction is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical
extraction (D7210).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lunesta tab 3mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no Part D or separate pharmacy benefit for this plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lunesta tab 3mg for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second level of a bilateral epidural steroid injection.
You asked the Plan to pre-approve the additional level. You say that this is medically necessary. The Plan denied your request. The Plan says a one level bilateral injection has already been approved.
The Plan must follow Medicare rules. The rules say that no more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). The request for a second level of bilateral injection cannot be approved, as it exceeds the limits set by the guidelines. Based on this information, we decided that Medicare rules for coverage of the additional level have not been met. Therefore, we decided that the Plan does not have to pre-approve a second level of a bilateral epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the reimbursement for the vaccination.

You asked the Plan to adjust the reimbursement for the vaccination provided out-of-network. You say that the enrollee should be reimbursed the full amount paid for the procedure. The Plan denied your request. The Plan says the enrollee was reimbursed the Medicare allowable for the procedure minus the $25 copayment.

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 $25 copayment for Physician services, specialist office visit.

The enrollee has been asked to pay a $25 copayment for the vaccination. The vaccination falls within the Physician services, specialist office visit benefit category. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. The Medicare allowable for this procedure is $155.25. This means that the enrollee was reimbursed the correct amount based on their contract with the Plan. Therefore, we decided that the Plan does not have to adjust the reimbursement for the vaccination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuroablation injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the limit has been exhausted.
The Plan must follow Medicare rules. Medicare rules say that there are benefit limits for pain injections. 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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent two sets of diagnostic medial branch blocks at three levels bilaterally. The request is for further radiofrequency ablation at three levels bilaterally. This request exceeds the utilization criteria, and is therefore 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve neuroablation injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for application of short leg splint, calf to foot (29515) walking boot, pneumatic and/or vacuum (L4361-LT).

You asked the Plan to pay for the splint and waling boot. You say that you were on call at the time the enrollee was hospitalized and surgery performed. Due to the severity of the injury and that there were no other approved in network providers on staff, it was deemed appropriate to perform surgery at the time of admission. The Plan denied your request. The Plan says 29515 denied as it is bundled to another service billed on the same day by the same physician, or physician of the same specialty in the same group. L4361 denied as it was billed with an incorrect place of 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. In this case, we have confirmed that 29515 has a bundled relationship with code 27759 and cannot be paid as billed. This code cannot be paid as a separate line item. We find that CPT code L4361 is not supported in the medical record. Specifically, the DME service was billed with an incorrect place of service. This DME was billed with the place of service 11 (office). Per the Medicare Claims Processing Manual, Chapter 20, section 10, the place of service for DMEs should indicate or reflect the location in which the item is being used. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for application of short leg splint, calf to foot (29515) walking boot, pneumatic and/or vacuum (L4361-LT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise equipment (A9300).

You asked the Plan to pay for the exercise equipment. You say that your doctor recommended that you not go to a gym during the pandemic. The Plan denied your request. The Plan says purchased made are not eligible for reimbursement.

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 up to a $150 Wellness Allowance in a calendar year. The Plan extended use of the Wellness Allowance benefit to include exercise equipment.

The Plan's rules for coverage of gym benefits have not been met because the purchase was made prior to October 1, 2020. Therefore, we decided that the Plan does not have to pay for the exercise equipment (A9300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is needed for you to be self-sufficient. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for septic shock, urinary tract infection, and pneumonia. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walking boot (L4361) provided on January 4, 2021, by an out of network (OON) provider.
You asked the Plan to pay for a walking boot. You say that the item provided was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered.
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 a walking boot (L4361) provided on January 4, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections.
You asked the Plan to pre-approve injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no failure of non-invasive treatment.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no imaging available of the cervical spine. There has not been an adequate trial of conservative therapy. This request is therefore considered not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require do not require daily inpatient skilled nursing and/or therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.