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

We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by an out-of-network (OON) provider on April 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without a primary care physician referral or prior authorization.
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, pre-approved care, and via the POS benefit option with a PCP referral. You are not a network provider with the Plan. The Plan did not receive a primary care physician referral and did not issue prior authorization for this service. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by an out-of-network (OON) provider on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the oral appliance (E0486) provided on March 18, 2021.
You asked the Plan to pay for the oral appliance. You say that you would like reconsideration because you believe this equipment should be covered by the Plan. The Plan denied your request. The Plan says that you did not receive prior authorization from the Plan before receiving this device.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the oral appliance by a contract provider. The file does not show that the Plan provided notice that the oral appliance would not be covered. Under Medicare rules, this means the oral appliance is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the oral appliance (E0486) provided on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on February 18, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87541, 87640, 87798, and 87532) provided on June 10, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87541, 87640, 87798, and 87532) provided on June 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 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-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services that can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH admission will be considered not medically reasonable and necessary as the transfer would not provide a clinical advantage over completing treatment at the current facility.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on March 8, 2021.
You asked the Plan to pay for the anesthesia for a patient of extreme age. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says The Plan says CPT code 99100 has a status indicator of B meaning that this service is always bundled into another service or procedure.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of the anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on March 8, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve more frequent home health services for the enrollee.

You asked the Plan to pre-approve the additional services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of being homebound.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 additional services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the plan has approved once weekly visits for the enrollee. The enrollee requires weekly assistance to set up his medication planner. There is no documentation of more frequent needs. As such, the frequency of requested, ongoing, home health skilled nursing services is not medically necessary or reasonable. 

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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve more frequent home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office and clinic visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office and clinic visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.

Therefore, we decided that the Plan does not have to pre-approve an office and clinic visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD) (no pulmonary function tests in the record), chronic obstructive pulmonary disease (OSA), and obesity hypoventilation syndrome. The enrollee may benefit from BiPAP during sleep. But Medicare does not cover a ventilator when used as BiPAP; certain BiPAP devices can provide the AVAPS mode of support. The denial of the ventilator is upheld.
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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.

You asked the Plan to pre-approve lumbar epidural steroid injections. You say that the enrollee is in continued
pain which could cause permanent nerve damage. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because the enrollee does not meet the criteria for lumbar epidural
steroid injections.

The Plan follows Medicare rules. Medicare rules state that lumbar epidural steroid injections may be covered
under certain clinical criteria.

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 lumbar epidural steroid injections. Our
reviewer says that the enrollee does not meet the Medicare criteria for the requested lumbar epidural steroid
injections. Our physician reviewer found the enrollee has been treated with medical therapy including opioids
and radiofrequency ablation. The provider has requested bilateral transforaminal epidural steroid injections at
L4-5 and L5-S1. No more than two transforaminal injections may be performed at a single 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 lumbar epidural steroid injections have not been met. Therefore, we decided
that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee's treating providers recommend therapy, and it is not safe for the enrollee to go home yet. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the electrocardiograms (EKGs) you had
on March 25, 2021, and March 27, 2021.
You asked the Plan to waive the copayments for the EKGs. You say that the Plan has stopped paying for your
EKGs. You said that the Plan needs to pay for these services at 100%. The Plan denied your request. The Plan
says you were charged these copayments correctly. The Plan says that because the allowed amount for each of
these EKGs ($14.80) is less than your copayment obligation, you are responsible for the full allowed amount
for each.
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 outpatient diagnostic tests.
You have been asked to pay a $35 copayment for the EKGs. As noted above, the allowed amount for each EKG is less than your copayment obligation, so you are responsible for the full allowed amount for each. The EKGs fall within the outpatient diagnostic tests benefit category. We understand that you believe this test is medically necessary and should therefore be covered fully. Maximus has no authority to direct health Plans on how to structure their copayments- that jurisdiction lies solely with the Centers for Medicare and Medicaid Services. 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 for the electrocardiograms (EKGs) you had on March 25, 2021, and March 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 2, 2021.
You asked the Plan to pay for the comprehensive exam. You say that you do not feel you have reached your maximum amount for dental care and do not understand why this was denied. The Plan denied your request. The Plan says you had a previous comprehensive evaluation in March of 2019, which is less than three years before the date in question. Your benefit covers one comprehensive exam every three years. Therefore, your benefit for this service is exhausted.
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. The Plan can cover one
comprehensive oral evaluation (D0150) every three plan years. Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive oral exam is requested in a frequency that exceeds what is covered under this benefit. Documentation shows you had a previous comprehensive exam less than three years prior which was covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs care at a long-term facility, and this transfer is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be unstable and should only require short-term additional acute care services that can be safely completed at the current facility.
The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH care will be considered not medically necessary, as transfer to an LTACH would not provide a clinical advantage over completing treatment at the current facility. Transfer may be considered when the enrollee is more stable. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid.
You asked the Plan to pre-approve Synthroid. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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-approve Synthroid.
Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery and lab services you
received at an outpatient hospital facility on August 5, 2020, and August 6, 2020.
You asked the Plan to waive the coinsurance for the outpatient surgery and lab services. You say that you
would like to dispute this charge. You did not provide a reason for your dispute in your appeal letter. The Plan
denied your request. The Plan says you were charged this coinsurance correctly
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 10%
coinsurance for lab services and outpatient surgery.
You have been asked to pay 10% coinsurance for the outpatient surgery and lab services. 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 coinsurance for the outpatient surgery and lab services you received at an outpatient hospital facility on August 5, 2020, and August 6, 2020.