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

We decided that the Plan does not have to pay for osteopathic manipulation and injection provided by a naturopathy provider from September 18, 2019 to September 19, 2019.
You asked the Plan to pay for naturopathy services. You say that this provider is licensed to provide these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a naturopath.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for the services of a naturopath only for office visits, second opinion visits, and urgent or emergent services. We looked at the Plan's rules and Medicare's rules. Although the Plan has a supplemental benefit that covers certain services provided by a naturopath, the services provided are not among those covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of naturopathy services have not been met. Therefore, we decided that the Plan does not have to pay for osteopathic manipulation and injection provided by a naturopathy provider from September 18, 2019 to September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 13,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told by the nurse that
you did not owe a copayment because you were only receiving a procedure. 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 $35
copayment for each specialist visit.
You have been asked to pay a $35 copayment for a specialist visit. As specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular intelligence (MI) profile testing provided on
December 18, 2019.
You asked the Plan to pay for genetic testing. You say that the ordering physician deemed that these tests were
medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because these tests are considered investigational and prior authorization for this testing was denied.
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 pay for genetic testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this molecular intelligence testing includes many tests in addition to the ones recommended by
the National Comprehensive Cancer Network (NCCN). Additionally, there is no information as to whether any
of the recommended tests had been performed previously. Therefore, the testing performed exceeded the
enrollee's medical needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not
have to pay for molecular intelligence (MI) profile testing provided on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on January 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records to support the code billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab service. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance
provided on December 5, 2019.
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that the dental
office did not check or tell you if you were eligible for the cleaning and exam. The Plan denied your request.
The Plan says these services exceeded the frequency limitations.
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, oral examinations are limited to two
per calendar year. The record shows that you received oral exams on February 21, 2019 and May 21, 2019 and
your oral examinations benefit was then exhausted. The contract also says that routine cleanings of the teeth
and/or periodontal (gum) maintenance is limited to up to three times per calendar year. The record shows that
you received cleanings on February 21, 2019, May 21, 2019, and August 28, 2019 and your routine cleanings
and periodontal maintenance benefit was then exhausted. Therefore, we decided that the Plan does not have to
pay for the periodic oral evaluation and periodontal maintenance provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950), crown (D2750), and maxillary partial denture (D5213).
You asked the Plan to pre-approve the core buildup, crown, and maxillary partial denture. You say that you
recommend a crown to prevent more food from accumulating and prevent the cavity from touching the nerve.
You say that you recommend a core buildup to prevent the tooth from breaking or receiving any other damage.
You also say that you recommend a partial denture to prevent loss of space and help the enrollee with basic
needs like eating and chewing. The Plan denied your request. The Plan says core buildup is not a covered
benefit. The Plan also says that the x-rays provided did not show that the that a crown or maxillary partial
denture are medically reasonable and necessary.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. The contract states that crown (D2750) and
maxillary partial denture (D5213) are covered services when they are determined to be medically necessary and
appropriate. The record shows that the Plan requested diagnostic x-rays, but they were not provided within the
given time frame. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including
any pins when required (D2950), crown (D2750), and maxillary partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D screening testing provided on January 7, 2020.
You asked the Plan to pay for screening test. You say that you are appealing with medical records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this test is not
covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that preventive vitamin assays are not covered by
Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of screening test have not been met. Therefore, we decided that the Plan does not have to pay for
Vitamin D screening testing provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the
enrollee on December 4, 2019.
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 Current Procedural Terminology (CPT) code 99152 remains not supported, as the the
documentation submitted did not indicate the presence of an independent trained observer to assist in the
monitoring of the enrollee'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 15minutes of intraservice time, patient age 5
years or older."
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
documentation submitted did not indicate the presence of an independent trained observer or anesthesiologist to
assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed
service cannot be verified. Of note, an independent trained observer is someone other than the physician
performing the services. It is noted that multiple attempts were made to contact the provider for additional
information. The review has determined that the records did not support the coding of CPT 99152.
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 pay for moderate sedation services (CPT 99152) provided to the enrollee on December 4, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for CPT code 73630 provided on November 5, 2019.
You asked the Plan to pay for CPT code 73630. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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, Medicare guidelines state that modifiers LT and RT are to be used to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to identify which of the paired organs was operated upon. In this case, procedure code 73630 is an x-ray of the wrist, minimum of 3 views, which is not considered to be a paired organ. The Plan has not provided any supporting documentation showing that procedure code 73630 is only payable if billed with modifiers 50, LT, or RT. Therefore, we decided that the Plan has to pay for CPT code 73630 provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. 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. The Plan said that there are in-network providers available for these services.
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 January 9, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided supports the need for care in an IRF. The Plan denied your request. The Plan says the notes do not show that the care needed requires the involvement of a doctor in the field of rehabilitation medicine. The Plan says that the notes do not show that the enrollee has complex care needs that require a coordinated team approach. The Plan says that the notes do not show that the enrollee must have an intensive therapy program in order to improve self-care functioning and walking. The Plan says that the enrollee's medical and therapy needs can be met in a skilled nursing unit.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the documentation does not indicate that the enrollee's functional level requires or can tolerate this therapy on an intensive level 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) injections every 6 months.
You asked the Plan to pre-approve Prolia. You say that the enrollee needs to continue Prolia injections because they have responded well to the previous injections. You also say that Denosumab (Prolia) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 pre-approve Prolia. Our reviewer says that the Prolia injections do not meet the Plan's coverage criteria. Our physician reviewer found review of compendia supports the use Prolia in males with osteoporosis or in males with osteopenia at high risk of fracture receiving androgen deprivation therapy - Prostate cancer. Our reviewer found that the documentation does not support either of these diagnoses. Our reviewer also found that medical necessity is not determined. 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 does not have to pre-approve Prolia (J0897) injections every 6 months.
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 the SNF services. You say that the enrollee does not have the strength to go home. You say that the enrollee needs rehabilitation or skilled nursing to be able to be successful in his recovery from bladder/prostate cancer surgery and chemo therapy. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee does not need skilled nursing or skilled therapy services on a daily basis.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, a need for IV antibiotics, or new enteral feedings. The enrollee's high functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy 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 the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires the involvement of a doctor in the field of rehabilitation medicine. The Plan says that the notes do not show that the enrollee has complex care needs that require a coordinated team approach. The Plan says that the notes do not show that the enrollee must have an intensive therapy program in order to improve self-care functioning and walking. The Plan says that the enrollee's medical and therapy needs can be met in a skilled nursing unit.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status appears to be not ready for a transfer to an IRF program and furthermore does not need close rehabilitation physician oversight. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not appear to require or be able to tolerate therapy in an IRF with an intensive level 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-approve acute inpatient rehabilitation facility (IRF) admission and services.