Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided from June 1, 2021, to June 24, 2021.  You asked the Plan to pay for the outpatient PT services. You say that you had authorization from this plan to cover these sessions. The Plan denied your request. The Plan says an Explanation of Benefits (EOB) was not received from your primary insurance. The Plan also says that until the primary EOB is received, the claim processed correctly.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made multiple attempts to contact the provider in this case to verify if a claim has been filed with your primary insurance. The provider in this case has failed to provide documentation showing that a claim for the services in this case has been submitted to your primary insurance. As the secondary insurer, the Plan cannot be held responsible for the outpatient PT services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided from June 1, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network physician services for the enrollee.  You asked the Plan to pre-approve out of network providers. You say that your spouse prefers to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.  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 pre-approved care. The 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. Therefore, we decided that the Plan does not have to pre-approve out of network physician services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the outpatient surgery services you had at an outpatient hospital facility on July 26, 2021.  You asked the Plan to reduce the copayment for the outpatient surgery. You say that you had this service at the center, so your copayment should only be $215. The Plan denied your request. The Plan says you were charged the correct copayment.  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 $265 copayment for outpatient surgery in an outpatient hospital facility.     You have been asked to pay a $265 copayment for the outpatient surgery. The facility where you received these services bills as an outpatient hospital facility, not an ambulatory surgical center. We also checked the Plan's online provider directory, and this facility is not listed in the Ambulatory surgery Center section. This provider is listed in the Hospital section of the provider directory. 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 reduce the copayment for the outpatient surgery services you had at an outpatient hospital facility on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive care management provided on May 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the comprehensive care management. You say that the service was medically necessary due to your medical condition. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the comprehensive care management provided on May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for astigmatism correcting function of intraocular lens (V2787) provided August 10, 2021.  You asked the Plan to pay for the vision services. You say that you had asked if the service would be paid by the Plan and the doctor told you that the correction of astigmatism of the lens is not covered. You paid for the service and did not have knowledge that it required authorization. The Plan denied your request. The Plan says the correction of astigmatism of the lens is not covered by the Plan.  The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.   While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for astigmatism correcting function of intraocular lens (V2787) provided August 10, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the Mohs micrographic technique (17311) provided on June 24, 2021.  You asked the Plan to pay for the Mohs micrographic technique. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the service at issue was not billed with an appropriate modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 17311 is supported in the record. Specifically, it is not appropriate to deny the surgery service because a pathology service was billed on the same day. The rule cited by the Plan is not appropriate for denying the surgical service. Additionally, the pathology service was not rendered by this provider. Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic technique have been met. Therefore, we decided that the Plan has to pay for the Mohs micrographic technique (17311) provided on June 24, 2021.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the famotidine injection coded S0028 provided on March 16, 2021.  You asked the Plan to pay for the famotidine injection. 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 payable.  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 S0028 is injection, famotidine, 20 mg.  We find that CPT code S0028 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the famotidine injection have not been met. Therefore, we decided that the Plan does not have to pay for the famotidine injection coded S0028 provided on March 16, 2021.
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 October 26, 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 submitted 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 and 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; initial 15 minutes of intraservice time, patient age 5 years or older   We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, CPT code 99152 requires the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. The documentation submitted does not support this. Additionally, CPT code 99152 is a technical component only code. This means that payment for CPT code 99153 is made to the facility and is the responsibility of the facility to any vendor. 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 October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 7, 2021.  You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0150 is covered only once every three years. The Plan says they previously paid for this code for date of service June 7, 2021.  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.  We looked at the file, the Plan's contract and Medicare rules. The Plan's contract clearly says that comprehensive oral evaluations are covered once every three years. The file shows that you previously received this service on June 7, 2021, which is less than three years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided from July 9, 2021, to July 21, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the member responsibility is too costly. The Plan denied your request. The Plan says you have been 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 $250 per day for days 1-7 and $0 per day for days 8-90 for each inpatient stay.   You have been asked to pay $1257.33, which is less than the maximum amount of $1750 for inpatient rehabilitation services. Inpatient rehabilitation services fall within the Inpatient Hospital Care 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 inpatient rehabilitation services provided from July 9, 2021, to July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation (99397) provided on October 14, 2020.
You asked the Plan to pay for 99397. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 99397 is not covered by Medicare or the Plan.
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 provider billed for an examination using procedure code 99397 provided on October 14, 2020. This procedure code is not covered as this is a code not used for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of 99397 have not been met. Therefore, we decided that the Plan
does not have to pay for the periodic comprehensive preventive medicine reevaluation (99397) provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fat grafting procedure (CPT code(s): 15772, 15771,
and 64788).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan
denied your request. The Plan says this type of surgery is considered not medically necessary/cosmetic.
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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that you underwent excision of a scalp lesion and have a partial wound
dehiscence. The record does not indicate that the requested procedure is more effective and beneficial than
other wound care modalities. The requested scare revision procedure is cosmetic in nature. The record provided
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested
service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
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 fat grafting procedure (CPT code(s): 15772, 15771, and 64788).
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 stay is not medically necessary based on IRF criteria. The Plan states that based
on your current needs, they suggest care with home health services at home with supervision or in an assisted
living facility. The state they also suggest care in long-term care with part-time skilled services, and if
something changes and you feel that you need intense rehabilitation, your request can be reassessed upon
appeal.
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 you are medically stable and do not meet Centers for Medicare & Medicaid Services
(CMS) coverage criteria for an IRF admission. With your current medical stability, and no other medical
complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3)
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic
medical conditions. You have no acute rehabilitation nursing needs. At the current functional level needing
contact guard assist (CGA) and stand by assist (SBA) for mobility, you do not require intensive therapies,
consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach
to daily therapy. IRF admission is not medically necessary. Document does not support the necessity for
admission to IRF. While you will benefit from continued physical therapy (PT), and occupational therapy
(OT), your rehabilitation needs can be safely met in an alternate and low intensity setting such as in-home with
therapies.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections for urge incontinence.
You asked the Plan to pre-approve the Botox bladder injections. You say that it is felt that this treatment is
necessary. The Plan denied your request. The Plan says the preferred treatments have not been tried and failed.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Botox bladder injections. Our
reviewer says that the requested use of Botox injections is not considered medically necessary t this time due to
step therapy rules. Our physician reviewer found the record indicates that the enrollee has urge
incontinence. The requested medication is a new start. The provided records do not indicate that the enrollee
has tried and failed the plan's preferred step one alternative, which is an anti-cholinergic medication and
Myrbetriq. The primary source record provided does not indicate that the enrollee has a contraindication to, or
would have an adverse effect from the plan' preferred step one alternative. The elements of the coverage
criteria are not satisfied.
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 Botox bladder injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve Botox injections for urge incontinence.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 are a 69-year-old female with a cerebrovascular accident, currently in an inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IDPN (CPT code(s): B4185, B4189, B4193, B4197, B4199, and B4224), for the enrollee.
You asked the Plan to pre-approve the IDPN. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IDPN have not been met. "Parenteral Nutrition Therapy Daily parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition." This means Medicare considers coverage of Parenteral Nutrition when a person's swallowing, stomach and intestinal system do not work. There was no indication the enrollee has a disease that keeps food from getting to their stomach and intestine. There was no report the enrollee's stomach and intestine do not work properly. The appeal information includes a statement from the enrollee's doctor that states, "Malnourishment is not due to clinical malabsorptive state so is not a good candidate for tube feeding, because they can take food and fluid by mouth." A malabsorptive condition is one where a person's stomach and intestines do not absorb nutrients. The enrollee does not have a condition that keeps food from getting to their stomach and intestine and they do not have a condition that keeps nutrients from being absorbed. Therefore, we decided that the Plan does not have to pre-approve IDPN (CPT code(s): B4185, B4189, B4193, B4197, B4199, and B4224), for the enrollee