Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health to be provided by an out-of-network provider.

You asked the Plan to pre-approve out-of-network psychiatrist services. You say that you have special needs and would like to continue to see the requested provider. The Plan denied your request. The Plan says there are in-network providers who can care for you.

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 behavioral health to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wrist hand finger orthosis (L3809) and the hand finger orthosis (L3924) provided on February 22, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the durable medical equipment provided.
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 20% coinsurance for durable medical equipment. You have been asked to pay $40.25 (Plan allowed amount of $201.23 x 20% coinsurance) for the durable medical equipment provided.
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 wrist hand finger orthosis (L3809) and the hand finger orthosis (L3924) provided on February 22, 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 for the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee can benefit from LTACH
services. The Plan denied your request. The Plan says that LTACHs do not provide a clinical advantage over a
non-LTACH acute care hospital.

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. The enrollee
was admitted for congestive heart failure exacerbation and a coronavirus lung infection. The enrollee continues
to receive acute care services, and these have not been denied. The medical record does not indicate that the
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH.

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulp vitality test (D0460) and cone beam (D0364).

You asked the Plan to pre-approve a pulp vitality test and cone beam. You say that the services are medically necessary. The Plan denied your request. The Plan says this service is not covered under the member s benefit package.

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. Specifically, the requested services are not listed in the Plan's benefit chart. Therefore, we decided that the Plan does not have to pre-approve a pulp vitality test (D0460) and cone beam (D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper overdenture (D5864) provided on March 22, 2021.

You asked the Plan to pay for the dental service. You say that you needed the partial denture to replace the front tooth which broke in a fall. You say that this denture was made necessary by an accident and should be covered. The Plan denied your request. The Plan says the partial upper overdenture 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 partial overdenture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper overdenture (D5864) provided on March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network facility.

You asked the Plan to pre-approve physical therapy You say that it would be beneficial for the member to be able to receive therapy at the requested facility without the burden for the family to try and obtain transportation. The Plan denied your request. 
The Plan says while the member is a part of the Plan, they must use network providers to get their medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-network providers.

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 physical therapy to be provided by the requested out-of-network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leg prosthesis (L5301, L5704, L5962) from a different vendor.
You asked the Plan to pre-approve the prosthesis. You say that you want to go to a different vendor due to a grievance filed against the approved provider. The Plan denied your request. The Plan says you have an appointment on 8/5/21 to pick up the approved prosthesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that you have already been approved for a leg prosthesis, and you have an approved appointment to go pick up the prosthesis. If you do not want to use this provider, the plan has also approved a new evaluation with a different vendor to discuss your prosthesis needs. There is no rationale as to why your specific requested vendor is needed over the multiple options given by the plan. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a leg prosthesis (L5301, L5704, L5962) from a different vendor
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 LTACH care is medically necessary. The Plan denied your request. The Plan says as acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in moving the enrollee from the current acute care hospital to an LTACH.
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 that there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 a special anesthesia service (99100) provided on June 8,
2020.

You asked the Plan to pay for anesthesia. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because this code is always bundled for
payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that payment for code 99100 is always subsumed by
the payment for the service to which it is incident.

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been
met. Therefore, we decided that the Plan does not have to pay for a special anesthesia service (99100) provided
on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional acupuncture treatments.

You asked the Plan to pre-approve the additional treatments. You say that you received a letter that stated you might be eligible for additional visits with a physician assistant. The Plan denied your request. The Plan says this request exceeds the benefit maximum limitation. 

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan benefit allows 20 acupuncture treatments per year. The records show as of July 14, 2021 you had used 18 of the 20 allowable visits. There are 2 visits left to this benefit and then the benefit will be exhausted. Therefore, we decided that the Plan does not have to pre-approve 10 additional acupuncture treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of an auricular stimulator coded as 64555 and L8679.

You asked the Plan to pre-approve the implantation of an auricular stimulator. You say that please see the attached letter and supporting documentation proving medical necessity for this prior authorization request. The Plan denied your request. The Plan says auricular neurostimulation is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implantation of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of an auricular stimulator coded as 64555 and L8679.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all
components and accessories, custom fabricated (L8702).
You asked the Plan to pre-approve the powered upper extremity range of motion assist device. You say that the
item is medically necessary. The Plan denied your request. The Plan says the item is experimental.
The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices 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 powered upper extremity range of
motion assist device. Our reviewer says that the requested item is not considered medically reasonable and
necessary in this case.
Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven
when used to help restore function to arms and hands paralyzed or weakened by a Cerebrovascular accident
(CVA stroke), brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or
injury. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term
outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity
paralysis/paresis.
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 powered upper extremity range of motion assist device have not been met.
Therefore, we decided that the Plan does not have to pre-approve the powered upper extremity range of motion
assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all
components and accessories, custom fabricated (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services represented by codes 82542 and 83789 provided on December 2, 2020.
You asked the Plan to pay for codes 82542 and 83789. 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. We find that CPT codes 82542 and 83789 are not supported in the medical record. Specifically, providers should report services to the highest specificity as documentation allows, and without unbundling procedures. CPT 82542 and CPT 83789 are inclusive to Healthcare Common Procedure Coding System (HCPCS) G0480, which was paid on this claim. Separate payment for these inclusive services is not allowed. Based on this information, we decided that Medicare rules for coverage of codes 82542 and 83789 have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services represented by codes 82542 and 83789 provided on December 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 26, 2021.
You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied your request. The Plan says coverage for a comprehensive oral evaluation is limited to 1 every 3 plan years. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on April 13, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for occupational therapy provided from April
1, 2021, through April 29, 2021.

You asked the Plan to reduce the copayment for the occupational therapy. You say that the hospital told you
there would be a $20 copayment and you cannot afford these copayments. The Plan denied your request. The
Plan says the copayments applied 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 a $150
copayment per visit for all other services furnished at a hospital outpatient facility (except for Cardiovascular /
Pulmonary Rehabilitation and Supervised Exercise Therapy).

You have been asked to pay $1,499.40, which is less than the standard $150 copayment per visit for the
occupational therapy. Occupational therapy falls within the "Outpatient hospital services" 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 reduce the copayment for occupational therapy provided from April 1, 2021, through
April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete root canal (D3332) provided on April 27, 2021.

You asked the Plan to pay for the dental service. You say that the dentist stopped in the middle of the procedure. You say that you are not working at this time. You say that you cannot pay for this service. You also say that the root canal is now incomplete, and you must have tooth # 31 under your bridge extracted. The Plan denied your request. The Plan says incomplete root canal 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 incomplete root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete root canal (D3332) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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 you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin. 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 pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 25, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the first claim was denied because it was for a specific problem and this claim was the first ever comprehensive oral evaluation. You say that this could not have been related to any other claim and the charge should be covered. The Plan denied your request. The Plan says this service is limited to one procedure every three 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 comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation provided on March 24, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on March 4, 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 99497 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of a discussion between the provider and patient regarding eventual end of life decisions and preferences. 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 advance care planning rendered on March 4, 2021.