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

We decided that the Plan has to pre-approve RFA (64635 and 64636).
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration as this service is
medically necessary. The Plan denied your request. The Plan says that the member has not tried and failed
physical therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 RFA. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation from the 1/30/20 progress note meets the criteria for a repeat RFA of the left
side.
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 RFA have been met. Therefore, we decided that the Plan has to pre-approve
RFA (64635 and 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say thatplans 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 wouldrequire the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora telephone evaluation and management service (99441) provided on August 21, 2019.You asked the Plan to pay fora telephone evaluation and management service. You say that this should be reprocessed for payment.The Plan denied your request. The Plan says this is not an eligible telehealth service.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services and corresponding current procedure terminology codes are listed on the CMS website at www.cms.gov/Medicare/Medicare-General-Information/Telehealth.We looked at the file and Medicare rules. The service at issue is not listed on the CMS website as an eligible telehealth service. The service at issue is not covered by Medicare.Therefore, we decided that the Plan does not have to pay fora telephone evaluation and management service (99441) provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 1, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 notpre-approve the servicesat issue. We found no exception that wouldrequire the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says there is no mention of subluxation in the x-ray or exam.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 services Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found Medicare guidelines state that the only service available to chiropractors is to treat a subluxation of the spine. This subluxation may be demonstrated by x-ray or by physical examination. The submitted medical chart notes dated April 3, 2018, May 28, 2018, July 17, 2018 and August 21, 2018 and December 2, 2018 reveal no findings that support a subluxation of the spine. The chiropractic chart notes/examinations, dated November 28, 2017, February 8, 2018, February 23, 2018, April 25, 2018, August 30, 2018 and October 18, 2018 reveal, mainly, positive orthopedic tests, decreased lumbar and/or cervical ranges of motion, muscular notations, spinal palpation findings/treatment listings and range of motion notations. These findings do not reveal a subluxation per Medicare guidelines. Thus, chiropractic treatment is not supported or allowed.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee can receive the care you need in another setting, such as home, a long-term care facility, or other outpatient setting.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.
You asked the Plan to pre-approve the device. You say that this would provide significant clinical and quality of life benefits. The Plan denied your request. The Plan says this is 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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental and investigational. More research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forradiation treatments provided on December 3, 2019 and December 4, 2019.You asked the Plan to waive the copayments forradiation treatments. You say that you feel that the charges are too high and cannot afford them.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $60 copayment for each radiation therapy service. You received radiation treatments on December 3, 2019 and December 4, 2019 for a total of 2 treatments. Therefore, you are responsible to pay a $60 copayment per each treatment. The total amount you owe is: $120.You have been asked to paythe total copayment amount of $120 for radiation treatments. Radiation treatments fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments forradiation treatments provided on December 3, 2019 and December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for drug testing. You say that you are appealing with documentation to support that
testing was administered at the request of the ordering physician. The Plan denied your request. The Plan says
the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the
ordering physician is also out-of-network with the Plan.
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 the medical services provided on August 28, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the 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 did not pre-approve the service at issue. We found no exception thatwould require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for genetic testing. You say that you are requesting payment of this claim because the enrollee's treatment options required this testing.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 the medical services provided on August 20, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve arthrocentesis with ultrasound guidance (20611).
You asked the Plan to pre-approve arthrocentesis with ultrasound guidance. You say that ultrasound guidance
necessary due to your condition. The Plan denied your request. The Plan says that the ultrasound guidance is
not medically necessary as it has not been necessary in the past for successful similar injections.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 arthrocentesis with ultrasound
guidance. Our reviewer says that the requested items/services are considered medically reasonable and
necessary in this case. Our physician reviewer found ultrasound guidance is medically reasonable in a patient
with morbid obesity and poor landmarks.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of arthrocentesis with ultrasound guidance have been met. Therefore, we decided
that the Plan has to pre-approve arthrocentesis with ultrasound guidance (20611).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99152) provided on August 20, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the record. Specifically, the record does not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on August 20, 2019.
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 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 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. Our physician reviewer found there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided through home-based care or at a custodial level with intermittent skilled services on a less than daily basis.We looked at this physician's review, the file, and Medicare rules. Based onthis 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 pay for physician services provided on August 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that these services were medically necessary.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. The Plan says that there are in-network providers 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 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 physician services provided on August 1, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aidsto be  provided by the provider.
You asked the Plan to pre-approve the hearing aids. You say that speech is very important to you and the ability to listen. You say that people could be talking to you and you hear ringing in your ears or you will miss what someone has said. You say that you can't hear what people are saying, you cannot hear the phone ringing and you cannot hear the television or music. You say that the physician at the provider, recommends that you use hearing aids. The Plan denied your request. The Plan says the Plan's UM Subcommittee Approved Authorization Guidelines, Binaural (Analog or Digital) Hearing Aids criteria has not been met. The hearing level in the right ear is 25 db and the hearing level in the left ear is 21 db. You can hear sounds softer than 35 db. Your hearing loss, as tested by audiology, does not meet the Plan's coverage criteria for this request.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare and Plan rules to determine if the Plan was correct in denying the request to pre-approve the hearing aids. Our reviewer says that coverage for hearing aids does not meet the Plan's coverage criteria. Our physician reviewer found that the Plan's criteria includes explicit audiology testing ranges. It appears from the testing that your level of hearing loss does not qualify you for coverage of hearing aids under the Plan's rules. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve the hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that at the time service was rendered you were not aware that the enrollee had this Plan. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on August 7, 2019 by an out of network (OON) provider.