Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the transfer to a long-term acute facility is not appropriate at this time.

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 in this case, the enrollee was admitted with acute hypoxic respiratory failure, multiple brain infarcts, and hyperthermia. The enrollee continues to receive acute critical 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. The elements of the coverage rules are not satisfied.

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint injection for L3-L4, L4-L5 and L5-S1 coded as 64493, 64494 and 64495.
You asked the Plan to pre-approve the injection. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says there is a different procedure, radiofrequency
ablation (RFA) that is better procedure. Records do not support why RFA cannot be used and so the requested
service 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 the injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is a 65-year-old male with chronic pain syndrome, and low back pain due to
multilevel degenerative changes of the lumbar spine, with symptoms of radicular pain, moderate neural
foraminal stenosis on the right at L3-L4 and bilaterally at L4-L5 and L5-S1, and mild to moderate spinal canal
stenosis at L4-L5. The enrollee is status post L4-L5 transforaminal epidural steroid injection on 7/14/2021. In
this case, the enrollee has a documented history of radicular pain. Therefore, it is not medically necessary or
reasonable for this enrollee to have injections as requested.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar/sacral facet joint injection for L3-L4, L4-L5 and L5-S1 coded as 64493, 64494 and
64495.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional features (L5981, L5986) for a leg prosthesis.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support a functional status of K3 ambulator.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed your medical need, as the physician documentation does not support that you are a level K3 ambulator, given your comorbidities and the documentation stating you use a walker for assistance with ambulation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features (L5981, L5986) for a leg prosthesis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 15, 2021.

You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

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, we have confirmed that code 70450 for the computed tomography has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory virus testing (87633) provided on April 16, 2021.
You asked the Plan to pay for lab test. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because multiplex respiratory viral panels of 6 or more pathogens are non-covered.
The Plan must follow Medicare rules. Medicare rules say that respiratory virus testing panel code 87633 is not covered by Medicare. We looked at the file and Medicare rules. This test is not covered by Medicare Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for respiratory virus testing (87633) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have not have to waive the copayment for podiatry services.
You asked the Plan to waive the copayment for podiatry services. You say that the provider caused you harm, which added additional medical bills from other providers. The Plan denied your request. The Plan says you have been charged 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 $50 copayment per visit for podiatry services. You have been asked to pay a total of $43, which is less than the $50 copayment for podiatry services. Podiatry services fall within the Podiatry 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 not have to waive the copayment for podiatry services.
Please note the record shows the Plan is handing the quality of care (QOC) concern. Please contact the Plan for any further questions regarding the QOC.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint (27096).
You asked the Plan to pre-approve the injection procedure for sacroiliac joint. You say that this requested
procedure is medically necessary for your pain. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
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 injection procedure for sacroiliac
joint. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found sacroiliac joint (SIJ) injections are recommended as an
option if the patient has failed at least 4-6 weeks of aggressive conservative therapy. Sacroiliac dysfunction is
poorly defined, and the diagnosis is often difficult to make due to the presence of other low back pathology
(including spinal stenosis and facet arthropathy).
In this case, there is no documentation of pain relief after the SIJ injection. There is no documentation to show
that you have had at least 50% pain relief for at least 6 weeks. The review has determined that the requested
sacroiliac joint injection 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 the injection procedure for sacroiliac joint have not been met. Therefore, we
decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint (27096).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior extensive therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been instructed in and is compliant in a home exercise program. The requested services are not part of a
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

E0668) provided on December 5, 2020, through December 10, 2020.
You asked the Plan to waive the deductible for the pneumatic compressor. You say that you would like
reconsideration because the provider should be paid in accordance to the FAIR Health data. The Plan denied
your request. The Plan says the out of network benefit for durable medical equipment was applied to the
member's deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1000 combined deductible which applies to durable medical
equipment.
The item or service you asked the Plan to waive the deductible for falls within the benefit category durable
medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$1000 combined deductible which applies to durable medical equipment. This cost sharing is a contractual
obligation that had not been met at the time the pneumatic compressor was received on December 5, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the pneumatic compressor
(E0651 and E0668) provided on December 5, 2020, through December 10, 2020. Of note, the Medicare
allowed amount for the pneumatic compressor is $109. The member has been asked to pay the correct amount.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Edarbi for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this drug is not covered under Part B.

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 Edarbi for the enrollee.

Benefits for this 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on May 18, 2021.

You asked the Plan to reduce the copayment for the office visit. You say that you should not be responsible for the $45 copayment because a nurse practitioner is not a specialist. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $15 copayment for provider and professional services at an in-network primary care physician's (PCP) office. 

The Plan says you must pay a $45 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $15 copayment for the office visit. The record shows the provider is a Family Nurse Practitioner. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on May 18, 2021.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 14, 2021.
You asked the Plan to waive the copayment for these services. You say that you have never had a copayment for outpatient hospital services. The Plan denied your request. The Plan says the copayment was 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 $75 copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
Review of the file shows that you received an endoscopy in the outpatient hospital setting on April 14, 2021. You have been asked to pay a $75 copayment for these services. These services fall within the outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoe inserts (A5500 and A5512).

You asked the Plan to pre-approve the diabetic shoe inserts. You say that the item should be covered. The Plan denied your request. The Plan says there are in-network providers available to supply these items.

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 the diabetic shoe inserts (A5500 and A5512).
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 would have a positive response to therapy and short-term rehabilitation is recommended. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140).
You asked the Plan to pre-approve a limited oral evaluation. You say that you were referred to a periodontist for services. The Plan denied your request. The Plan says the service at issue is not covered unless it is performed by a participating general dentist. Dental services performed by a periodontist are not covered.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the service at issue is not covered unless it is performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380) and the consultation (D9310) provided on March 4, 2021.
You asked the Plan to pay for the dental services. You say that you are disappointed with the representative and the provider's receptionists. You say that the plan representative called the provider's office to determine if the services were medical or dental, but they did not realize that the provider had opted out of Medicare. You also say that you would not have had the services done if you had known they would not be covered because you do not have funds available to pay for such a procedure. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made to providers that have opted out of Medicare.
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 covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, payment cannot be made for dental services received by a provide that has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380) and the consultation (D9310) provided on March 4, 2021.
Your complaint about being misled by the plan representative and dental office receptionist is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided April 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that you were on an extended trip and required dental services due to pain. The Plan denied your request. The Plan says dental services are not covered when provided OON.
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 covers the limited oral exam and intraoral x-ray when the services are obtained from a provider in the Plan's dental vendor network. We looked at this physician's review, the file, and Medicare rules. The services in this case were obtained from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and intraoral x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided April 28, 2021, by an out-of-network (OON) provider.