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

 We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 2, 2021, to July 9, 2021.  You asked the Plan to pay for codes J0604-AX and 90999. 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 as billed.  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 J0604 is Cinacalcet, oral, 1 mg (for ESRD on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.  We find that CPT codes J0604-AX and 90999 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of codes J0604-AX and 90999 have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 2, 2021, to July 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve the inpatient psychiatric services. You say that the records provided support the need for inpatient mental health services. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of inpatient psychiatric care. The Plan says that the enrollee does not have any medical problems that require hospital care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. The enrollee was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis.  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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for catheters purchased out of network on July 8, 2021.  You asked the Plan to pay for this purchase. You say that the catheters you need to use are not in network. The Plan denied your request. The Plan says you were provided several options to retrieve these catheters in network.  Medicare rules say that plans can require enrollees to get care prior authorization. The contract with the Plan states that durable medical equipment may require prior authorization. The provider in this case is not a network provider with the Plan. The Plan provided a list of vendors who confirmed they could provide this specific catheter in network. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for catheters purchased out of network on July 8, 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 treatment of infection with IV antibiotics, renal monitoring, cardiac support, and close medical monitoring with daily physician involvement. You say that the enrollee meets the admission criteria, and his ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed could be provided in another setting.  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 medical needs can be safely met in the acute setting. Adding LTACH services will not add any value to the current care. There is no need for complex wound care or mechanical ventilation. Clinical stability can be safely achieved in the current setup and then can be tapered to lower level of care. There is no need for prolonged inpatient admission. Skilled Nursing Facility (SNF) or home-based care can safely provide the care. There are no additional services that LTACH can provide that cannot be provided in the acute inpatient setting. The requested LTACH services are not medically justified and will amount to over utilization of services and futile care and will expose the enrollee to increased risk of infections.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met with home health care.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for thoracic compression fracture after a series of recent falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).  You asked the Plan to pre-approve SI joint RFA. You say that the requested sacroiliac joint RFA is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint RFA is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SI joint RFA. Our reviewer says that the requested sacroiliac joint RFA is not medically necessary. Our physician reviewer found the enrollee is with a history of chronic low back pain. She is status post spinal fusion at L4-L5-S1.  She had a spinal cord stimulator (SCS) implant with revision and is status post SCS explant on November 5, 2020. On physical exam she has bilateral sacroiliac tenderness, + Faber bilaterally, + Fortin finger test bilaterally. Her provider has recommended a sacroiliac joint radiofrequency ablation (RFA).    According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain.  Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary.  The review has determined that the requested SI joint RFA is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 14, 2021.  You asked the Plan to pay for the eye refraction. You say that this service was medically necessary and could not have been performed by an optometrist as it was provided for medical reasons. The Plan denied your request. The Plan says Medicare does not cover eye refractions. The Plan offers a supplemental benefit to cover this service, but it must be performed by a provider in the Plan's specified routine vision network in order to be covered. The provider in this case does not participate in this network; therefore, payment is denied.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are performed as part of a routine vision exam by a provider in the specified routine vision network.  We looked at the file and the Plan's rules. The eye refraction in this case was rendered for medical purposes and was performed by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on June 29, 2021.  You asked the Plan to pay for the annual wellness visit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you received an annual wellness visit on June 16, 2021, which was less than 12 months prior to the annual wellness visit received on June 29, 2021.  The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the spinal MRI provided on December 1, 2020.  You asked the Plan to waive the copayments for the spinal MRI. You say that these claims should be covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $375 copayment for in-network diagnostic radiology other than computed tomography (CT) scans. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $375 copayment for the spinal MRI.  You have been asked to pay a $300.89 copayment for the spinal MRI. The spinal MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the spinal MRI provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan and magnetic resonance imaging (MRI) of the thoracic and lumbar spine.  You asked the Plan to pre-approve the CT scan and MRI. You say that this imaging is medically necessary. The Plan denied your request. The Plan says there has not been a trial of conservative management for conditions related to the thoracic and lumbar spine to warrant advanced imaging at this time.  The Plan must follow Medicare rules. Medicare rules say that CT scans and MRIs 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 CT scan and MRI. Our reviewer says that the requested imaging of the mid and lower spine is not considered medically reasonable and necessary. Our physician reviewer found the enrollee has no current red flag symptoms and has not had a recent trial of physical therapy for spinal pain. More conservative measures should be tried prior to advanced imaging.  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 CT scan and MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan and magnetic resonance imaging (MRI) of the thoracic and lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and fluoride (D1208) provided on June 23, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that this has been your provider for over 30 years. You say that the plan advised your dentist that the services were covered at 100%. You say that the plan advised the crown would be covered at 50%. You say that you were only advised that you would need to pay up front and submit a claim for reimbursement since the provider was out of network. You also say that yo The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for any amount greater than what the plan pays. The Plan also says that the cost share was applied correctly.  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 and the services are listed as covered, dental services received out of network are paid based on the allowed amount. Out of network providers may bill you for any amount greater than what the Plan pays. Additionally, the record shows that the Eligibility Summary states that it is not guarantee of eligibility, benefits, or payment. Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and fluoride (D1208) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on August 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the claim was submitted with all Medicare-approved codes, and they should be covered. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 19, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).  You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that the dentures are damaged, and it is hard for you to eat. The Plan denied your request. The Plan says these benefits are only available once every 5 plan years.  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, you also have a maximum benefit of one complete upper and lower denture every five plan years. The Plan paid for Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of the LINX reflux management system for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says since coverage is not available for the LINX reflux management system, the subsequent removal of the device will also not be covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.     We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found aside from the upper gastrointestinal x-ray that was provided, there were no motility studies perform to assess the enrollee's dysphagia. There were not endoscopic nor abdominal imaging results to address the complaint of epigastric pain. The available records do not support that the surgical removal of the LINX device will result in a net clinical benefit.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of the LINX reflux management system for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 4, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell down and could not get up and no one was around to help you. You say that you called 911 and they sent an ambulance to help. The Plan denied your request. The Plan says your Plan covers ambulance transportation only when you are transported by ambulance. Since you were not transported by ambulance, the service is not covered under your Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on February 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy visits (97112, 97163, 97530) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve physical therapy visits. You say that you do not agree with the denial and would like the decision overturned. The Plan denied your request. The Plan says this service is available by a provider in your 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.  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 records provided for review do not show that the services at issue are urgent or emergent. 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 physical therapy visits (97112, 97163, 97530) to be provided by an out-of-network (OON) provider.