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

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.You asked the Planto pre-approvethe SNF admission. You say that even if you are not approved for SNF services that is still where you need to return because that is where you live so the stay needs to be approved.The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage. Based on the criteria you could be cared for at a lower level of care like an extended care facility at which you already live.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveDenosumab (Prolia).You asked the Plan to pre-approveProlia. You say that the enrollee had to stop oral alendronate due to side effects.The Plan denied your request. The Plan says that Prolia is only covered for postmenopausal women with osteoporosis.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Prolia. Our physician reviewer found that the fibula fracture appears tobe low trauma or spontaneous. It would be reasonable to use an IV bisphosphonate in this case. However,it appears as if the provider doesnot want to use this due to emotional lability experienced with oral bisphosphonate. As the FRAX score is in a range where medication to lower fracture risk and increase BMD is indicated, the use of Proliais supported.There is no indication that Prolia is unsafe in this situation.Therefore, the requested service is medically reasonable and 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 Prolia have not been met.Therefore, we decided that the Plan has to pre-approveDenosumab (Prolia)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cone beam CT capture and interpretation providedon May 8, 2019.You asked the Plan to pay forthe cone beam CT capture and interpretation. You say that you were required to pay for these services up front at the time of the appointment. You also say that this provider stated that they no longer filed claims directly with you plan.The Plan denied your request. The Plan says this service is not covered by your plan.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 pay forthe cone beam CT capture and interpretation provided on May8, 2019.Your complaint about your frustrating experience with "the plan" is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMetoprolol Succinate tab 100mg ER for the enrollee.You asked the Planto pre-approvethedrug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered 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 Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveMetoprolol Succinate tab 100mg ER for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe electrocardiogram, cardiovascular stress test, TC myocardial perfusion imaging, injection, and Tc-99m sestamibi provided from July 11, 2019 to July 17, 2019 by the out of network provider.You asked the Planto pay forthe physician services. You say that you received care at an out of network clinic due to an emergency. You also say that you were advised the services would be covered.The Plan denied your request. The Plan says that the services could have been provided in network. The Plan also says that authorization was not obtained before you received the services.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved 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 pay for the physician services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee could not have foreseen requiring the services prior to leaving her service area. The abnormal EKG finding were not previously known and could not have been anticipated. The records indicate that the care provided was medically necessary. It would not have been medically reasonable to delay the services 6 months. The evaluation of the abnormal EKG needed to be done expediently.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 physician services have been met.Therefore, we decided that the Plan has to pay forthe electrocardiogram, cardiovascular stress test, TC myocardial perfusion imaging, injection, and Tc-99m sestamibi provided from July 11, 2019 to July 17, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient psychiatric detoxification services provided July 5, 2019 to July 10, 2019.You asked the Plan to pay forthese services. You say that the inpatient psychiatric detoxificationservices were medically necessary.The Plan denied your request. The Plan says the inpatient psychiatric detoxification services provided were not medically necessary and could have been provided at a lower level of care. Additionally, the services were denied based on a lack of prior authorization.  The Plan must follow Medicarerules. Detoxification for acute alcoholism or alcohol withdrawal necessitates the constant availability of physicians and/or complex medical equipment found only in the hospital setting, inpatient hospitalcare during this period is covered when reasonable and 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 pay for these services. Our reviewer says that the services provided donot meet criteria for coverage. Our physician reviewer found the health plan's denial of inpatient psychiatric detoxification services appears appropriate.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrolleedoes not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe resin filling, one surface, (D2330) for tooth # 22, the resin filling, 4 or more surfaces, (D2335) for teeth # 23 and 24provided on September 24, 2019.You asked the Plan to pay forthe dental services. You say that you are not financially prepared to pay for the entire cost of the fillings. You say that the office advised you would likely only be responsible for half of the total billed amount.The Plan denied your request. The Plan says that the frequency limit for the services you received have been exceeded.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. We found that the Plan did not substantiate their claim that the frequency limit of once per 48 months has been exceeded. The documentation that was submitted to us does not show that teeth # 22, 23, and 24 had fillings within the past 48 months.Therefore, we decided that the Plan has to pay forthe resin filling, one surface, (D2330) for tooth # 22, the resin filling, 4 or more surfaces, (D2335) for teeth # 23 and 24 provided on September 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEliquis 5mg tablets.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is an oral medication.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 Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveEliquis 5mg tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe presumptive and definitive drug testing panels provided on June 12, 2019.You asked the Planto pay forthe drug testing panels. You say that the lab provided the testing that was ordered by the treating provider which is considered medically necessary.The Plandenied your request. The Plansaysthatthe order form does not specify the testing to be performed and is not considered valid.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. In this case, the documentation in the file supports that the Plan was provided with the order form and the lab results from the testing at issue. However, the Plan did not provide this in the original case file. The original file consisted of only a form which defined the customized panel for the ordering provider, which incidentally does match the billed services. The reviewer requested the order form and results and the Plan returned documents pertaining to another date of service. We find that there is evidence that the Plan has not forwarded all documents related to this request. The denial rationale is based on the order form being insufficiently specific as to what is on the customized panel, though the file we do have clearly defines the customized panel. We find that this denial is not supported.Therefore, we decided that the Planhas to pay forthe presumptive and definitive drug testing panels provided on June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided to the enrollee on April 29, 2019 and billed under procedure code 51785.You asked the Plan to pay forthis service. You say that this claim should be paid as the codes billed are supported by the records.The Plan denied your request. The Plan says Medicare billing criteria are not met. The Plan stays that the provider billed procedure codes 95938-TC-59, 51785-TC-59 and 95870-TC-59 x2. On October 18, 2019 procedure codes 95938-TC-59 and 95870-TC-59 x2 were approved and procedure code 51785-TC-59 was denied because the code was not supported by the medical records. The Plan says that based on the NationalCorrect Coding Initiative Policy Manual for Medicare Services, for code 51785-TC-59, the physician places a pad or needle in the anal or urethral sphincter and measures the electrical activity with the bladder filled and during emptying. These codes imply that the service is performed by, or under the direct supervision of, a physician or other qualified health care professional, and that all instruments, equipment, fluids, gases, probes, catheters, technician's fee, medications, gloves, trays, tubing, and other sterile supplies be provided by the provider. These codes have both a technical and professional component. To claim only the professional component, append modifier 26. To claim only the technical component, the providemust append a modifier TC. To claim the complete procedure (i.e., both the professional and technical components), the claim is submitted without a modifier. The guidelines stated when codes 51784 or 51785 are performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. Code 51784 should not be reported with 51792.This description was not documented in the technical report narrative. ThePlan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.According to (CPT) code definitions and guidance, this case involves an inappropriate billing of (CPT) code 51785-TC-59. (CPT) code 51785-TC-59 is not supported in the documentation therefore is not payable. Therefore, we decided that the Plan does not have to pay forservices provided to the enrollee on April 29, 2019 and billed under procedure code 51785.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts provided on July 18, 2019.You asked the Plan to pay forthe diagnostic casts. You say that the provider took casts of your teeth because you have difficulty eating and they needed to see how your jaw and teeth came together. You also say that you do not understand why this procedure is not covered because it is very important for the continued treatment that you need.The Plan denied your request. The Plan says this service is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe diagnostic casts provided on July 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81292, 81295, 81298, 81317, 81401, 81403, 81404, 88237) provided on June 18, 2019 by out of network provider.You asked the Plan to pay for laboratory services. You say that you don't have the information on patient's insurance requirements, limitations or conditions. You say that the patient didn't physically attend your facility. You say that he had a routine exam at the referring physician's office and your services are an extension of the initial visit. You say that you processed the accepted specimens and reported your findings back to the doctor.The Plan denied your request. The Plan says the provider is a non-network provider that does not work with the health plan and a non-network provider, referred the member. The primary care provider did not refer the member. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 forlaboratory services (81292, 81295, 81298, 81317, 81401, 81403, 81404, 88237) provided on June 18, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from July28, 2019 through July 31, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that this admission was warranted and supported by clinical documentation in the medical record. The treating physician exercised their expert opinion in electing to admit this patient out of concern that the patient's symptoms were attributed to an escalating clinical condition.The Plan denied your request. The Plan says that the patient was admitted to the hospital for fainting. The Plan also says that the patient did meet for observation level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that atthe time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 28, 2019 through July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 4 resin-based composites provided on September 25, 2019.You asked the Plan to pay forthe 4 resin-based composites. You say that you weretold multiple times that this procedure was covered.The Plan denied your request. The Plan says the benefits for these services have already been satisfied and the frequency limitation has been exceeded.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, restorations are limited to two procedures per calendar year. The record shows that you received 2 resin-based composites on September 18, 2019 and your restorations benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe 4 resin-based composites provided on September 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-network.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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.