Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 18, 2021.
You asked the Plan to pay for the dental service. You say that your dentist determined that 2 of your teeth needed to be pulled. You say that you were referred to an oral surgeon due to being on a blood thinner. You say that when you went to the oral surgeon you only discussed your medications and pulling your teeth. You also say that this should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. 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 limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 21, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided February 7, 2021.
You asked the Plan to pay for subsequent hospital care. You say that you are asking for reconsideration of this
claim as this is being denied due to missing medical records. Please review and reprocess this claim
accordingly. The Plan denied your request. The Plan says missing patient medical record for this service.
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 99233 is subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval
history; A detailed examination; Medical decision making of high complexity.
We find that CPT code 99233 is not supported in the medical record. Specifically, medical records are needed
to support that the service CPT 99233 for the date of February 7, 2021. Medical records were requested from
the provider without success. Based on this information, we decided that Medicare rules for coverage of
subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for
subsequent hospital care (99233) provided February 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 16, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 16, 2021, forward. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.
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 inpatient psychiatric care from September 16, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 16, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 16, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee'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 inpatient psychiatric care from September 16, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 16, 2021, forward.
Appeal type: Transportation
Decision: Unfavorable

You asked the Plan to pay for the services provided. You say that the enrollee's death was pronounced during the ambulance services. The Plan denied your request. The Plan says the claim was not billed according to guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. A modifier is used if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In this case, ambulance records were not provided to indicate whether billing guidelines were followed.. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on March 1, 2021.We decided that the Plan does not have to pay for the ambulance transportation services provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necesasary. The Plan denied your request. The Plan says this is considered investigational.
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 the requested procedure is experimental. More research is needed to show safety and efficacy of the procedure for back pain treatment. 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 the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you have issues with your vision that restrict you from operating a vehicle. The Plan denied your request. The Plan says you have exceeded the limits set in your subscriber agreement.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 42 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options (K0861) including a power tilt/recline seating system (E1007), and power elevating legrests (E1012).
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that it is felt that the PWC requested is what is medically necessary for this enrollee. The Plan denied your request. The Plan says review of the records does not support that the multiple power options are medically necessary. Approval could be granted for a Group 3 PWC with no power options if such a request were made.
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC base with multiple power options, described by code K0861, may only be covered if the enrollee also meets the requirements for a power tilt/recline seating system. 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 Group 3 PWC with multiple power options. Our reviewer says that the criteria for the requested type of PWC are not met in this case. Our physician reviewer found the enrollee is a 45-year-old woman with a medical history that includes myotonic muscular dystrophy. The enrollee suffers from muscle stiffness, muscle cramping and exertional fatigue. The enrollee requires assistance with bathing but is able to dress independently if seated. She is also independent with feeding, hygiene, grooming and toileting. She does not have any pressure injuries or need for self-catheterizing. She is no longer able to propel herself in a manual wheelchair due to progressive weakness. The enrollee does suffer from a neurological disorder with functional/mobility deficits. Criteria for a Group 3 PWC are met; however, the requirements for the PWC with multiple power options are not met. The documentation does not indicate that the member has any pressure injuries or requires intermittent catheterization of the bladder nor is there documentation of increased tone of spasticity. As such, the criteria for the power tilt/recline seating system with power elevating legrests are not met. 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 Group 3 PWC with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options (K0861) including a power tilt/recline seating system (E1007), and power elevating legrests (E1012).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist services provided on April 1, 2021.
You asked the Plan to waive the coinsurance for specialist services. You say that you would like to know what charges you owe. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 30% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received specialist services from an out-of-network provider on April 1, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $312.83 and 30% of that is $93.85.
You have been asked to pay the total coinsurance amount of $93.85 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 coinsurance for specialist services provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that medical records substantiate medical necessity. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 30, 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 continues to have complex needs. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for LTACH admission.

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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion.
You asked the Plan to pre-approve arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (22614). You say that the enrollee needs this lumbar fusion surgery. The Plan denied your request. The Plan says there is no image report of an unstable spine.
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 arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (22614). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal surgery not met. There is no documented instability or fracture. There is no severe stenosis on 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 arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (22614) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulators (TENS) unit (E0730).
You asked the Plan to pre-approve a TENS unit. You say that the item is medically necessary. The Plan denied your request. The Plan says you are not in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered if the beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD 160.27. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. Specifically, you are not enrolled in a clinical trial. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulators (TENS) unit (E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit for the enrollee. You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found chronic low back pain is specifically excluded from coverage, outside of clinical trials. Therefore, the 
request is deemed 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an magnetic ressonance imaging proton density fat fractionation (MRI-PDFF) in combination with magnetic resonance elastography (MRE).

You asked the Plan to pre-approve an MRI-PDFF with MRE. You say that the requested tests are more accurate. The Plan denied your request. The Plan says that this is not necessary at this time.

The Plan must follow Medicare rules. Medicare rules say that 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 an MRI-PDFF with MRE. Our reviewer says that the requested imaging is medically necessary. Our physician reviewer found while a Fibroscan is generally adequate for most Nonalcoholic steatohepatitis (NASH) patients, your body mass index (BMI) is greater than 35, which means the requested MRI-PDFF in combination with MRE is appropriate and medically necessary for optimal accuracy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI-PDFF with MRE have been met. Therefore, we decided that the Plan has to pre-approve an magnetic ressonance imaging proton density fat fractionation (MRI-PDFF) in combination with magnetic resonance elastography (MRE).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on February 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on February 12, 2021.