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

 We decided that the Plan does not have to pay for the drug testing provided on August 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON drug testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says this was ordered by an OON provider without authorization. This was not emergent and could have been provided in-network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 for the drug testing provided on August 16, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).  You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan denied your request. The Plan says that the requested service is not covered when performed within 12 months of a comprehensive oral evaluation.  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, the Plan has not provided documentation to substantiate the limitations for the requested service. We requested this documentation, but nothing was received. Without documentation to show the limitations of this service, it cannot be determined that the limitations have been met. Therefore, we decided that the Plan has to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection rendered on April 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 96374 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 96374 (therapeutic, diagnostic, or prophylactic injection) and 21453 (closed treatment of mandibular fracture). Code 96374 is a column II code with a modifier indicator of 1 when billed with column I code 21453. Code 96374 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the injection rendered on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on March 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 36245 is not supported.  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 36245 is selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family.  We find that CPT code 36245 is not supported in the medical record. Specifically, there is no documentation of selective catheter placement into the arterial system. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pain management office visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the office visits. You say that the services are medically necessary. The Plan denied your request. The Plan says there are 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve pain management office visits to be provided 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 it is felt that IRF care is needed. The Plan denied your request. The Plan says this level of care exceeds the enrollee's need.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of nonunion of prior radial fracture. She was discharged home on 12/22/21 and has several falls at home since discharge. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that these services are being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by an out-of-network provider on March 16, 2021.  You asked the Plan to pay for a complete maxillary denture. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says the rendered dental work 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 Plan does not have to pay for a complete maxillary denture (D5110) provided by an out-of-network provider on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the new patient visit provided on September 22, 2021.  You asked the Plan to pay for the new patient visit. You say that this is being denied against a claim for a nurse practitioner who works under vascular surgery. This provider is plastic surgery. The Plan denied your request. The Plan says both claims were billed by providers with the surgery taxonomy. As such, this is not considered a new patient visit.  The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient that has not been seen by a physician in the same group of the same specialty within the prior three years.  In this case, the enrollee was seen by a provider with Surgery as their specialty in February 2021. Since both providers are Surgery specialists, this is not a new patient per Medicare rules. Therefore, we decided that the Plan does not have to pay for the new patient visit provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on June 10, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered to prevent deep vein thrombosis.  The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement.  The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0673, E0675) provided to the enrollee on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 2, 2021.  You asked the Plan to pay for the dental service. You say that you feel the cleaning that you received satisfies the definition of preventive dental services and cleanings. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.  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 periodontal maintenance is not among those covered under this benefit. The Evidence of Coverage clearly states that coverage is limited to those services set forth in the Schedule of Covered Procedures. If a service is not listed, it is not included and is not covered. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network pain treatment for the enrollee.  You asked the Plan to pre-approve out of network care. You say that this treatment is medically necessary. The Plan denied your request. The Plan says this treatment can be provided in network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. You are 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 out of network pain treatment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an implant placement (D6010) for teeth # 19, 22, 27, and 30, and an implant supported removable denture (D6111).  You asked the Plan to pre-approve the dental services. You say that you cannot chew properly. You say that you cannot follow your diet because you have an allergy to dentures. You also say that you need a dental implant. The Plan denied your request. The Plan says implant placement is not listed as a covered service. The Plan says that implant supported removable denture is not listed as a covered service either.  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 implants and implant supported removable denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant placement (D6010) for teeth # 19, 22, 27, and 30, and an implant supported removable denture (D6111).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for outpatient mental health visits you had from September 15, 2021, to September 30, 2021.  You asked the Plan to waive the coinsurance for the outpatient mental health visits. You say that you were told these services would be covered in full. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan confirmed that you were not given incorrect information.  The phone records show that you were informed that telemedicine visits were covered in full, but if you see a provider in the office, then coinsurance applies.  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 20% coinsurance for outpatient mental health services.   You have been asked to pay 20% coinsurance for the outpatient mental health visits. These were in-office visits, not telehealth visits. 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 outpatient mental health visits you had from September 15, 2021, to September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve stockings to cover a prosthesis (L8499).  You asked the Plan to pre-approve stockings to cover a prosthesis. You say that this was covered in the past. The Plan denied your request. The Plan says this is not a medical item.  The Plan must follow Medicare rules. Medicare rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.  We looked at the file and Medicare rules. The file indicates that the stockings at issue have been requested to improve appearance rather than to improve function. Based on this information, we decided that Medicare rules for coverage of stockings to cover a prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve stockings to cover a prosthesis (L8499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transit system (K0108) for a wheelchair.  You asked the Plan to pre-approve a transit system. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been met.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit system (K0108) for a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve colchicine tablets.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 colchicine tablets.   Benefits for self-administered drug 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pre-approve the requested LDCT scan. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   We reviewed the file and the Medicare rules. We find that the enrollee last received a LDCT scan on June 21, 2021.  The enrollee is not eligible for an annual LDCT scan until June 21, 2022.  Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs are custodial and, 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (82565, 84315, G0483) rendered by the out-of-network (OON) provider on June 2, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services (82565, 84315, G0483) rendered by the out-of-network (OON) provider on June 2, 2021.