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

We decided that the Plan does not have to pay for the office visits provided from July 26, 2021, through
September 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON office visits. You say that you went to this provider who is a family
friend because you wanted to avoid the emergency room due to COVID. The Plan denied your request. The
Plan says there are many in-network providers in your area who could have provided the care at issue. There is
no evidence that you contacted the Plan to inquire about this or that you requested authorization for these OON
services.
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 office visits provided from July 26, 2021,
through September 9, 2021, by an out-of-network (OON) provider.
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 is stable and ready for transfer. The Plan denied your request. The Plan says the enrollee no longer needs continued treatments that can only be provided in a hospital 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 physician reviewer found that the enrollee is receiving inpatient acute care with weakness, worsening of his lung disease, and anemia. Treatment has greatly improved his condition. 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.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the clinical value of bone marrow aspirate has not been demonstrated in peer-reviewed literature.
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 requested services. Our physician reviewer found that bone marrow aspirate remains experimental when used as bone graft material in spinal surgery. More research is needed to show its safety and efficacy. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone bitartrate/acetaminophen.

You asked the Plan to pre-approve hydrocodone bitartrate/acetaminophen. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 hydrocodone bitartrate/acetaminophen.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 10 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 10 additional PT visits. You say that the requested services are medically
necessary. The Plan denied your request. The Plan says that the requested services are 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 10 additional PT visits. Our reviewer
says that skilled services are necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the records 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 for physical therapy, by or under the supervision of a
therapist. While the provider notes that it is unclear if the enrollee can walk again due to being deconditioned it
is reasonable to attempt additional physical therapy to see if the enrollee can progress, and also to transition to
an independent home exercise program. The requested services are not part of a maintenance program, but the
specialized skill, knowledge and judgment of a qualified therapist is 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 10 additional PT visits have been met. Therefore, we decided that the Plan has
to pre-approve 10 additional physical therapy (PT) visits.

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 diagnostic colonoscopy with biopsy
you received at an ambulatory surgery center on September 14, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told this
procedure was covered. The Plan denied your request. The Plan says you were charged this copayment
correctly because this was a diagnostic colonoscopy.

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 $295
copayment for diagnostic colonoscopies.

You have been asked to pay a $295 copayment for the diagnostic colonoscopy. 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 diagnostic colonoscopy with biopsy you received at an ambulatory surgery center on September 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The
Plan denied your request. The Plan says a SNF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have documented
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were
not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs, custodial and intermittent, could, as a practical matter, be provided at a lower level of
care (ex. home, assisted living, long term 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on August 30, 2021.

You asked the Plan to pay for the SelectMDx testing. You say that this test was medically necessary and should be covered. The Plan denied your request. The Plan says this testing can only be covered after an initial prostate biopsy, and there is no evidence at such a biopsy occurred.

Please note: We found that the rationale cited by the Plan refers to a different test than the test at issue in this case. As such, we disregarded this rationale.

Medicare rules say that molecular diagnostic laboratory tests such as SelectMDx are subject to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and unique test identifier from the DEX Diagnostic Exchange. 

We looked at the file and Medicare rules. Per review of the DEX Diagnostic Exchange, the SelectMDx test was reviewed through the MolDX process and was found to not meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87482 provided on June 25, 2021.

You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 87482 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification. 

We find that CPT code 87482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87482 provided on June 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
August 4, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you believe you were
discharged from the hospital too early, so you shouldn't have to pay this. The Plan denied your request. The
Plan says you were charged this copayment 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 $300
copayment for ambulance services.

You have been asked to pay a $300 copayment for the ambulance services. This copayment applies regardless
of the reason for the transport. 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 ambulance services you received on August 4, 2021.
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 the previous therapy you received was not aggressive enough for you to resume normal daily activities without assistance. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.

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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for repeated falls and was transferred to skilled nursing on December 20, 2021. She was discharged home on January 12, 2022 and has ongoing weakness and multiple falls despite outpatient therapy services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy, 1 to 3 teeth per quadrant (D4211), precision attachments (D5862 x 6), initial periapical x-ray (D0220), additional periapical x-ray (D0230), and unspecified preventive service (D1999 x 3), implant maintenance (D6080), and second stage implant surgery (D6011 x 2) provided from December 2, 2020, to December 10, 2020.

You asked the Plan to pay for the dental services. You say that it was explained to you that the treatment your dentist requested would be covered by your plan. You say that you received a bill for $6,100. You also say that there must have been some confusion between the dental office and your plan. The Plan denied your request.

The Plan says that the gingivectomy, precision attachments unspecified preventive services, and implant related services are not listed as covered. The Plan says that 1 initial periapical x-ray, and 1 additional periapical x-ray are covered per year. The Plan also says that these frequency limits have 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, the gingivectomy, precision attachments unspecified preventive services, and implant related services are not among those covered under this benefit. Additionally, the frequency limits for periapical x-rays have been exceeded. The record shows that the Plan paid for an initial and additional periapical x-ray that you received on November 3, 2020. Therefore, we decided that the Plan does not have to pay for the gingivectomy, 1 to 3 teeth per quadrant (D4211), precision attachments (D5862 x 6), initial periapical x-ray (D0220), additional periapical x-ray (D0230), and unspecified preventive service (D1999 x 3), implant maintenance (D6080), and second stage implant surgery (D6011 x 2) provided from December 2, 2020, to December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services at a peri-implant capsulectomy of the breast (19371) provided on May 28, 2021.

You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for surgical assistant services have not been met.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 19371. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services at a peri-implant capsulectomy of the breast (19371) provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 8, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you thought an out-of-network provider was covered with a charge. The Plan denied your request. The Plan says the provider was an out-of-network provider so payment for the service was denied.

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 an office visit provided on October 8, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), four osseous surgeries (D4260 x4), and occlusal adjustment (D9952) provided from September 1, 2021, to September 21, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation, osseous surgeries, and occlusal adjustment. You say that these procedures were for an infection which was removed to prevent the spread of the infection. The Plan denied your request. The Plan says these procedures are not covered under your dental plan.

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 the comprehensive periodontal evaluation (D0180), four osseous surgeries (D4260 x4), and occlusal adjustment (D9952) provided from September 1, 2021, to September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.

You asked the Plan to pre-approve the requested device. You say that the enrollee's condition has impacted his
quality of life. The Plan denied your request. The Plan says unproven procedures are 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 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 requested device. Our physician
reviewer found that interspinous stabilization devices remain experimental. More research is needed to show its
safety and efficacy. Therefore, the requested services are not considered 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 requested device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level respiratory assist device without back-up rate (E0470) and heated humidifier (E0562).

You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your request. The Plan says that records provided do not indicate a sleep study was completed.

The Plan must follow Medicare rules. Medicare rules say that a sleep study must be performed before a a bi-level respiratory assist device without back-up rate can be covered. 

We looked at the file and Medicare rules. The file does not indicate a sleep study has been performed. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve a bi-level respiratory assist device without back-up rate (E0470) and heated humidifier (E0562).