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

We decided that the Plan does not have to pre-approvelumbar facet joint injections.You asked the Plan to pre-approvethe lumbar facet joint injections. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says all three exams since fall injuryover 4 months are tele-video visits without any physical exams or testing to indicate source of pain and there is no documentation of physical therapy, diet changes, HEP, ice, heat, or chiro care.The Plan must follow Medicare rules. Medicare rules saythat 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 lumbar facet joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found all three exams since the injury over past 4 months were tele-video visits without physical exams or testing to indicate the source of pain. There is documentation of radiculopathy, there is evidence of a non-facet cause of the pain (T12 compression fracture) and there were no clinical assessments to implicate the facet joint as the putative source of pain.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 lumbar facet joint injections have not been met.Therefore, we decided thatthe Plan does not have to pre-approvelumbar facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D6751, D6241).You asked the Planto pre-approvethe services. You say that you have a lot of medical issues and need this work done.The Plandenied your request. The Plansaysthis is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D6751, D6241).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine provided on September 10, 2020.You asked the Plan to pay forthe vaccine. The Plan denied your request. The Plan says this is not a covered service.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan followsthe same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for acupuncture services provided to the enrollee on August 7, 2020.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says that
The Plan must follow Medicare rules. The rules say that acupuncture is now covered under limited circumstances. 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. The plan has not substantiated their denial. The plan has not provided any medical records from the date of service in question. Medical records are needed to fully review the medical necessity of the acupuncture services in question. Acupuncture can be covered for chronic low back pain. The enrollee's diagnosis is "other chronic pain." Low back pain can be a symptom of this diagnosis. Additionally, the contents of the June 12, 2020 call to verify benefits is unclear. The provider claims they were told that acupuncture is covered, and the plan claims that the provider was told there was no benefit for acupuncture. The provider has provided proof of their statement, while the plan has not provided any proof that they told the provider acupuncture was not covered. Therefore, we decided that the Plan has to pay for acupuncture services provided to the enrollee on August 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the psychiatric evaluation provided on January 7, 2020.

You asked the Plan to waive the coinsurance for the psychiatric evaluation. You say that you did not see the provider who is billing you. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.

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. The Plan did not send the medical records. This means we cannot confirm if the enrollee received services from this provider. Therefore, we decided that the Plan has to waive the coinsurance for the psychiatric evaluation provided on January 7, 2020.
 
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 pay for the prophylaxis (D1110) provided on July 7, 2020.
You asked the Plan to pay for the dental service. You say that your coverage includes 2 cleanings per year. You
say that your first appointment was on February 4, 2020, and your second was on July 7, 2020. You say that
due to Covid-19 and safety measures, your appointment was then made in July instead of August.
The Plan denied your request. The Plan says 1 prophylaxis every 6 months is covered, up to 2 visits every
calendar year. The Plan also says that the frequency limit 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, the frequency limit of 1 prophylaxis
every 6 months has been exceeded. The record shows that the Plan paid for prophylaxis that you received on
February 4, 2020, less than 6 months before. Therefore, we decided that the Plan does not have to pay for the
prophylaxis (D1110) provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the neck (70491) performed on November 5, 2020. You asked the Plan to waive the copayment for a CT scan of the neck. You say that you have no money to pay this amount. The Plan denied your request. The Plan says the correct copayment was applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for CT scans for each service date. You have been asked to pay a $213.58 copayment for a CT scan of the neck. A CT scan of the neck falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 a CT scan of the neck (70491) performed on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee would benefit from IRF level of care.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform 15 hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation.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 Plandoes not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance imaging (MRI) services (72146, 72148) provided on February 28, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe MRI services. You say that this service was medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, paymenthas been correctly denied.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 forthe magnetic resonance imaging (MRI) services (72146, 72148) provided on February 28, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from August 7, 2020, to August 13, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you cannot afford the charges.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 $250 copayment per day for days 1-7 for inpatient hospital coverage. You had an inpatient hospital stay from August 7, 2020, to August 13, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-6 (August 7, 2020, to August 12, 2020). $250 (copayment) x 6 (inpatient days) = $1,500. You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital coverage benefit category. This means that you have been asked to pay the correct amountbased 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 foran inpatient hospital stay provided from August 7, 2020, to August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGenicular nerve block.You asked the Plan to pre-approveGenicular nerve block. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that arenot 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 Genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had chronic Left knee pain after a total knee replacement. The enrollee has tried a Nome Exercise program, PT, nonsteroidal anti-inflammatory drugs, opiates and oral steroids. The enrollee has a spinal cord stimulation device in place. The requested service is considered an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the enrollee does not meet criteria for the requested 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 Genicular nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approveGenicular nerve block
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forchiropractic services (CPT 99212, 99203, 97110, 97035) received from May 27, 2020 to August 26, 2020.You asked the Planto pay forthe services. You say that you chose to eliminate surgery by using non-surgical treatments for health issues.The Plandenied your request. The Plansaysthese services are not covered when billed by a chiropractor.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. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plandoes not haveto pay forchiropractic services (CPT 99212, 99203, 97110, 97035) received from May 27, 2020 to August 26, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOmeprazole 20 mg capsule.You asked the Plan to pre-approveOmeprazole. You say that this is medically necessary for the member's medical condition.The Plan denied your request. The Plan says this medication does not fall under Part B.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 Plan does not have to pre-approveOmeprazole 20 mg capsule.Benefits for Omeprazolemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcardiovascular riskassessment testing (CPT Code(s): 81286, 81404, 81407, 81408, 81479) provided on June 10, 2020.You asked the Plan to pay forthe testing. You say that the testing is necessary.The Plan denied your request. The Plan says the services are non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The member had cardiovascular risk assessment testing on June 10, 2020.  The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.Medicare non-coverage applies to both contracted and non-contracted providers, and cannot be overridden by plan directed care.[Any and all codes on this claim are denied, and in addition, previous payments to this provider for this member are subject to recoupment.]Therefore, we decided that the Plan does not have to pay forcardiovascular risk assessment testing (CPT Code(s): 81286, 81404, 81407, 81408, 81479) provided on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBrovana.You askedthe Plan to pre-approvethe Brovana. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug, Perforomist (Formoterol). The Plan also says that there is no indication Perforomist would likely be less effective, and/or cause adverse effects for the enrollee.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Brovana 15 mcg/2 ml solution. Our reviewer says that Brovana is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is on appropriate inhaler therapy for asthma, but there is no indication that the enrollee is unable to appropriately use the inhaler. Our reviewer also found that there is no reason that Perforomist would be less effective for the enrollee.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 Brovana 15 mcg/2 ml solution have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana.
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 you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbarfusion. Her medical conditions are stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePET with CT for Attenutation.You asked the Plan to pre-approvethe PET with CT for Attenuation. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says this service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PET with CT for Attenuation. Our reviewer says that this service is not medically necessary. Our physician reviewer found the CT Angio does not show splenomegally or adenopathy.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 PET with CT for Attenuation have not been met.Therefore, we decided that the Plan does not have to pre-approvePET with CT for Attenutation.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to reduce your cost-share for amedical eye exam (92014) received on June 18, 2019.You asked the Plan to reduce your cost-share for amedical eye exam. You say that the cost share was incorrectly applied.The Plan denied your request. The Plan says that the cost share was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must paya $50 copay for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. The Plan says you must pay a 20% coinsurance for diagnosticservices. Based on the Plan contract, however, you cannot be asked to pay more than a $50 copay for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.This means you were charged an incorrect coinsurance of $73.08 instead of the correct copayment of $50.Therefore, we decided that the Plan has to reduce your cost-share for amedical eye exam (92014) received on June 18, 2019.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 toopen the case again, we will send you a letter.