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

We decided that the Plan does not have to pre-approve facet joint injections at 3 levels.
You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 facet joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have low back pain secondary to lumbar spondylosis and lumbar facet arthropathy. You are treated with medical therapy including opiates, water therapy, and physical therapy. You are status post bilateral lumbar facet medical branch blocks on May 11, 2021 and reported greater than 50% relief of pain. No more than four therapeutic facet joint nerve blocks per year are reimbursable with two levels per region, per session, after the appropriate documentation of 80% improvement with diagnostic blocks for the duration of the local anesthetic, and with a total relief and improvement of at least 50% of 6 weeks (including greater than 80% relief and greater than 50% relief). The documentation does not support that you meet criteria for the requested facet injections at three levels.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L34832 to support their denial. However, LCD L34832 is retired. This means we cannot use LCD L34832 to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections at 3 levels
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on November 24, 2020 by a non-network provider.

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 the services were rendered by a non-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 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 outpatient mental health services provided on November 24, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits (99203) electrical stimulation (unattended) (97014) hot or cold pack therapy (97010) and therapeutic ultrasound (97035) provided June 3, 2021 to June 29, 2021.
You asked the Plan to pay for the chiropractic services. You say that you feel that the services should be covered in full because you called the Plan to get your benefits for the service and feel that you were not told the right information when you called in. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visits (99203) electrical stimulation (unattended) (97014) hot or cold pack therapy (97010) and therapeutic ultrasound (97035) provided June 3, 2021 to June 29, 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met.

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 that 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 does require physical therapy and occupational therapy services, but based on the medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the records provided, there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility appears to be appropriate in this case. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that the enrollee has to prick their fingers four times per day. The Plan denied your request. The Plan says there is no documented insulin use.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for coronary artery disease risk testing (81493) provided on September 4, 2020.

You asked the Plan to pay for coronary artery disease risk testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of coronary artery disease risk testing have not been met. Therefore, we decided that the Plan does not have to pay for coronary artery disease risk testing (81493) provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network provider.
You asked the Plan to pre-approve physical therapy to be provided with an out-of-network provider. You say that you need physical therapy for low back and leg pain. The Plan denied your request. The Plan says there are network providers available.
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 an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 18, 2021.

You asked the Plan to pay for the dental service. You say that you still have not received your reimbursement for the service. The Plan denied your request. The Plan says reimbursement was issued on May 9, 2021 in the amount of $18. The Plan says that the provider in this case is out of network. The Plan says that if you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, out of network dentists may bill you for the difference between the INFS and dentists' charged fees. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer 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 at the time of this request, there is no documentation provided necessitating admission to a LTACH. 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 he 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 service 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 the moderate sedation services (99152 and 99153) provided on December 11, 2020.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services 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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT codes 99152 and 99153 are not supported in the record. Specifically, the documentation does not show that an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status was present. CPT code 99152 cannot be verified. CPT code 99153 is a technical component only code. Payment for the technical component is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152 and 99153) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for visits you had with an infectious disease specialist on May 10, 2021, and May 11, 2021.

You asked the Plan to waive the copayments for the specialist visits. You say that you had these services while you were an inpatient in the hospital. You say that you didn't visit the specialist's office, so no copayment should apply. The Plan denied your request. The Plan says you were charged these copayments 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 $30 copayment for specialist services, including care in a hospital outpatient department. 

You have been asked to pay a $30 copayment for each of the specialist visits. Records show that you were in an observation stay at the hospital on the dates of service in question. You were not admitted to the hospital as an inpatient. Observation is considered an outpatient status. Your Evidence of Coverage says that the specialist visit copayment applies to services you receive in an hospital outpatient department. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for visits you had with an infectious disease specialist on May 10, 2021, and May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on March 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on April 14, 2021.
You asked the Plan to pay for the preventive procedure. You say that there is only one in-network dentist in your area and they are not accepting new patients. The Plan denied your request. The Plan says this service is 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. 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 preventive procedure (D1999) provided on April 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 30, 2020.

You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment for a preventative colonoscopy. 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 a $0 copayment for colorectal cancer screenings and a $290 copayment for diagnostic colonoscopies. 

The record shows that you had a colonoscopy on September 30, 2020. The claim was submitted with the diagnosis of constipation. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $290 copayment.

You have been asked to pay a $290 copayment for a colonoscopy. A colonoscopy falls within the colorectal cancer screenings 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 a colonoscopy provided on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on March 1, 2021.

You asked the Plan to waive the coinsurance for denosumab (J0897) and therapeutic, prophylactic, or diagnostic injection (96372). You say that you were never in the hospital for such treatments. The Plan denied your request. The Plan says the medical records show you were seen at the facility.

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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for denosumab (J0897) and therapeutic, prophylactic, or diagnostic injection (96372). denosumab (J0897) and therapeutic, prophylactic, or diagnostic injection (96372) falls within the Medicare Part B prescription drugs 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. The record shows the services were provided at the hospital outpatient center. Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on March 1, 2021.