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

We decided that the Plan does not have to pay for the services provided to you on July 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.

You asked the Plan to pre-approve a Vertiflex Superion interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 additional crowns.
You asked the Plan to pre-approve 13 additional crowns. You say that the approval for two crowns is not appropriate to fix the patient's issues. You say that the patient will need all 16 crowns and the benefit should be reconsidered. The Plan denied your request. The Plan says 13 crowns remain denied.
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, there is a maximum benefit of one crown per calendar year. Therefore, we decided that the Plan does not have to pre-approve 13 additional crowns.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. You say that the coding for this claim is correct. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 laboratory testing provided on April 16, 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 acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records show that it is not reasonable to expect that the enrollee will be safely able to participate in three (3) hours of therapy five (5) days a week, or 15 hours of therapy a week. The Plan states the enrollee's records show that they tire quickly and get short of breath. The Plan states the enrollee has a long history of right sided weakness and it is thus not reasonable to expect that the enrollee would be able to fully benefit from, nor necessarily actively participate in, the intensity of services of an IRF. The Plan states the enrollee will benefit from skilled nursing care and therapy after this hospital stay. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility or home with home health services.
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 right sided weakness and chronic subdural hematoma after a fall. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99282) provided on August 4, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment per visit for emergency care. You have been asked to pay a $90 copayment for the emergency room visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit (99282) provided on August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dry needling.
You asked the Plan to pre-approve the dry needling. You say that you would like reconsideration because you have tried cortisone shots, physical therapy and chiropractor for lower back pain and were referred for dry needling. The Plan denied your request. The Plan says dry needling is not a covered benefit for your condition.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 
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 dry needling. Our reviewer says that the criteria for the request for dry needling have not been met. Our physician reviewer found the documentation does not support that you have chronic low back pain which has lasted 12 weeks or longer. 
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 dry needling have not been met. Therefore, we decided that the Plan does not have to pre-approve the dry needling.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF)
care provided from May 7, 2020, through May 29, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment per day, for day 1 through day 20 for skilled nursing facility (SNF) care. Additionally, enrollees pay
a $170 copayment per day, for day 21 through 100 for SNF care.
You have been asked to pay $340 ($170 copayment x 2 days) for the inpatient skilled nursing facility care
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care
provided from May 7, 2020, through May 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0429) provided on May 16, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $250 copayment for the Medicare-covered one-way ground ambulance trip provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0429) provided on May 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluzone High Dose Quad 2021-22 vaccine.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a past medical history of polyarthralgia, chronic pain syndrome and secondary adrenal insufficiency. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Fluzone High Dose Quad 2021-22 vaccine meets Medicare criteria as medically reasonable and necessary for the enrollee. There is no Medicare-approved major drug compendia support for the use of the Fluzone High Dose Quad 2021-22 vaccine for a patient less than 65 years of age. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Fluzone High Dose Quad 2021-22 vaccine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission to an inpatient psychiatric facility for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says care can occur safely in a different setting.
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 the admission.
Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician
reviewer found based on a review of the records, it was not expected that this enrollee would improve in a
reasonable period of time. The enrollee does not have dangerousness to self or others, and was not showing any
auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care
as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services
appears appropriate.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve an admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental filling (D2335) provided on July 30, 2021.
You asked the Plan to pay for a dental filling. You say that the Plan should cover half of the payment since you get new benefit coverage every quarter. You also say it is also a lot cheaper than needing to get a replacement tooth. The Plan denied your request. The Plan says the maximum allowance for the filling has been paid.
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 a dental filling once every 36 months. We looked at the file and Medicare rules. The records show that you had a filling on April 7, 2020 and the EOC confirms you are allowed one filling every 36 months. Therefore, you have exhausted your maximum allowed benefit. Based on this information, we decided that the Plan's rules for coverage of a dental filling have not been met. Therefore, we decided that the Plan does not have to pay for a dental filling (D2335) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 8, 2020.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services for dialysis for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee is bed-confined and suffers with poor
trunk control. The Plan denied your request. The Plan says ambulance rides are covered if the enrollee's
condition requires an ambulance transport with trained medical staff.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 medically reasonable or necessary. Our physician reviewer found the enrollee's
presenting symptoms do not meet prudent layperson criteria for emergency care for these scheduled nonemergent
dialysis sessions. There was no evidence provided of unstable vitals or other acute condition to
suggest an emergency. The documentation does not support that other means of transport (such as stretcher
van) are contraindicated. The documentation does not support that the enrollee needs the expertise, services and
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport.
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 ambulance services for dialysis for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90832) service(s) provided in the
office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
(99051) provided on April 25, 2021, by an OON provider.
You asked the Plan to pay for the psychotherapy services. You say that the service performed, 90832, is a
routine benefit for outpatient mental health. Kindly reprocess the claim to pay in full. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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 individual psychotherapy (90832) service(s)
provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to
basic service (99051) provided on April 25, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services provided on April 22, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you were told the surgeon could do the procedure in her office. The Plan denied your request. The Plan says the cost share 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 $250 copay for outpatient surgery.
You have been asked to pay a $250 copay for the services provided. The services fall within the outpatient surgery 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 cost share for the outpatient surgery services provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular genetic testing (81291, 81401, 81403, 81404, 81405, 81406, 81407, 814081 81439, 81479) provided on November 10, 2020.
You asked the Plan to pay for hereditary cardiovascular genetic testing. You say that this was billed correctly. 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 hereditary cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic testing (81291, 81401, 81403, 81404, 81405, 81406, 81407, 814081 81439, 81479) provided on November 10, 2020.