Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and you can receive services at a lower level of 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) monthly supplies for device coded as K1018 (K1019 x4).

You asked the Plan to pre-approve the Cala Trio device. You say that you are requesting an appeal for the denial of the Cala watch. The enrollee has tried and failed medications for her tremors. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the enrollee's health problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cala Trio device have not been met. Therefore, we decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) monthly supplies for device coded as K1018 (K1019 x4).
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. The Plan denied your request. The Plan says you will not improve with LTACH care.  

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 you are currently undergoing treatment at an acute care hospital (ACH) following a hemorrhagic stroke.   

You have received a tracheotomy and feeding tube. You have been weaned from the ventilator but are likely not a candidate for decannulation. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.   

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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2021.  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 not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 14, 2021.  You asked the Plan to pay for the limited oral exam. You say that you feel this service should have been billed as a new patient visit not as a limited, problem-focused exam. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 limited oral evaluation - problem focused (D0140) provided September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the second resin-based composite - three surfaces, anterior (D2332) provided September 27, 2021.  You asked the Plan to pay for the second filling. You say that your insurance covers more than one filling. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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 filling once per calendar year.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that one filling was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of fillings has been exceeded. Therefore, we decided that the Plan does not have to pay for the second resin-based composite - three surfaces, anterior (D2332) provided September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided on September 24, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $125 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.        You have been asked to pay a $125 copayment for an ultrasound. Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 an ultrasound (76705) provided on September 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve five home health physical therapy visits.  You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says a skilled therapist is not needed for home assistance, and needs can be met by a caregiver.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not have documented skilled therapy needs. You are not shown to have an acute decline in function. You appear to be functioning at a level commensurate with a lower level of care (i.e. home exercise program, outpatient therapy). You have an available caregiver. As such, the requested home health physical therapy is not shown to be medically necessary or reasonable.  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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device 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 unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 the device is experimental. More research is needed. 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 the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device 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 unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 this device is experimental. More research is needed.  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 the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 8, 2021.  You asked the Plan to pay for psychotherapy 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 have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on September 29, 2021, and October 20, 2021.

You asked the Plan to waive the copayment for eye surgery. The Plan denied your request. The Plan says there is a $175.00 copayment for each Medicare covered surgery at an ambulatory surgical center.

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 $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $175 copayment for eye surgery. The eye surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 eye surgery provided on September 29, 2021, and October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Injection(s), anesthetic agent(s) and/or steroid; brachial plexus (64415-59) provided on July 21, 2021.  You asked the Plan to pay for code 64415-59. You say that the medical records support the use of modifier -59 with code 64415 provided on July 21, 2021. The Plan denied your request. The Plan says the medical records do not support the use of modifier -59 with code 64415 provided on July 21, 2021.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.     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 pay for code 64415-59 Our reviewer says that the medical records do not support the use of modifier -59 with code 64415 provided on July 21, 2021. Our physician reviewer found the anesthesia report does not support anesthetic agent was given for post op pain, and therefore cannot be verified.  CMS does not cover anesthetic injections separately unless for post op pain. CPT codes 64400-64530 (Peripheral nerve blocks - bolus injection or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes shall not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Modifier 59 or XU may be used to indicate that a peripheral nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia, and a procedure note shall be included in the medical record.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 64415-59 have not been met. Therefore, we decided that the Plan does not have to pay for the Injection(s), anesthetic agent(s) and/or steroid; brachial plexus (64415-59) provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on October 18, 2021, by an OON provider.  

You asked the Plan to pay for the crowns and core buildup. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered when provided OON.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contracts says that you are responsible for 100% of the cost of crowns when provided OON.     

We looked at the file, and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the crowns and core buildups have not been met. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on October 18, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection rendered on September 27, 2021.  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 are not covered.    The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met.   The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography of the thorax (71260) provided on August 12, 2021.  You asked the Plan to waive the copayment for a computed tomography of the thorax. You say that the provider confirmed this was just a routine exam of breasts, nothing out of the ordinary and the results were normal. The Plan also says that the script the provider wrote was for an annual exam. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per day, per provider, for Medicare-Covered diagnostic radiology services.      You have been asked to pay $178.41, which is less than the $275 copayment for a computed tomography of the thorax. A computed tomography of the thorax falls within the Medicare-Covered diagnostic radiology services benefit category. The record shows the copayment was applied to the computed tomography of the thorax and not a mammogram. 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 computed tomography of the thorax (71260) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot insert (L3020), provided on August 23, 2021.
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot insert (L3020), provided on August
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 10, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care. 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 physician services provided on September 10,
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that that you are not able to return to your assisted
living in this condition because you are at risk of further injuries and even death. The Plan denied your request.
The Plan says that you no longer require skilled services and the continuation of SNF 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 necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF services.
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 continued skilled nursing facility (SNF) services.