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

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s).

You asked the Plan to pre-approve destruction by neurolytic agent. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions for pain management are covered under specific circumstances. 

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 destruction by neurolytic agent. Our reviewer says that the services are not medically necessary. Our physician reviewer found Medicare states non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation are considered not reasonable and necessary. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the copayment for the drug administration services you received from a hospital infusion center on May 3, 2021.
You asked the Plan to waive the copayment for the drug administration services. You say that you already paid the $50 copayment for the Prolia injection itself, but now you are being billed another $50, doubling the price. The Plan denied your request. The Plan says that when your claim initially processed, it incorrectly assessed a $50 copayment for the administration services. The Plan says that the administration services should have had a $35 copayment because they were received in a specialist's office. The Plan says it has reprocessed the claim to show that you owe a $35 copayment for the administration services in addition to the $50 copayment for the Prolia itself.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). In addition, it is the Plan's obligation to provide enough documentation to support their assessment of cost sharing. We looked at your contract with the Plan. In this case, we do not find that the Plan has supported their argument that their assessment of a $35 copayment for the administration services is correct. While we agree that Plans are permitted to charge cost sharing for administration services separate from the drug itself, the Plan has failed to properly explain why they charged $35. In its case file, the Plan says that this $35 was charged because you received these services in a specialist's office. This is problematic for three reasons. First, it appears as though you had these services in a hospital infusion center, not a doctor's office. Second, even if you had these services in a specialist's office, the cost sharing for specialist services is only $30 (in-network) according to page 112 of the Evidence of Coverage, not the $35 that is being charged. Third, the Plan has failed to identify whether or not the hospital infusion center is a network provider. Without this information, we cannot ascertain what benefit category cost sharing should apply.
This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the drug administration services you received from a hospital infusion center on May 3, 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for periodontal scaling and root planing provided on July 2, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that authorization was obtained for the services rendered and the denial should be reconsidered. The Plan denied your request. The Plan says that this service is allowed two times per calendar year.
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 two visits for periodontics every year. We looked at the Evidence of Coverage, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have been met. The Plan says that periodontal scaling and root planing is limited to twice every year. The Evidence of Coverage clearly says that two visits for periodontics are covered every year. The Plan only paid for one visit for periodontal scaling and root planing on June 18, 2021. Therefore, we decided that the Plan has to pay for periodontal scaling and root planing provided on July 2, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on May 29, 2021.
You asked the Plan to pay for medical nutrition therapy. You say that you attached the medical records and payment of the claim should be reconsidered. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes, renal disease, or for non-functioning structures that normally permit food to reach the stomach and digestive tract.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on May 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 7) provided on March 10, 2021, and the emergency treatment of dental pain (D9110) provided on May 14, 2021.
You asked the Plan to pay for the dental services. You say that you previously had a tooth extracted. You say that your mouth was not healing properly. You say that you were experiencing pain. You also say that you feel you should not be responsible for these bills. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says the frequency limit has been exceeded. The Plan also says that emergency treatment of dental pain is not listed as a covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a the initial periapical x-ray that you received on March 10, 2021. Additionally, the emergency treatment of dental pain is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 7) provided on March 10, 2021, and the emergency treatment of dental pain (D9110) provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a genomic sequencing panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are not safe to be discharged due to cognitive issues. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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 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 skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the comfort face down recovery system (A9270).
You asked the Plan to pay for the comfort face down recovery system. You say that this was medically necessary due to surgery because you were unable to hold your head up for more than 10 minutes per hour. The Plan denied your request. The Plan says this type of equipment is considered to be a precautionary device and can be used for other purposes other than for the treatment of an illness or injury and is noncovered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the comfort face down recovery system (A9270).
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on February 6, 2020, through February 10, 2020 at the Diagnosis Related Group (DRG) 637 payment level.
You asked the Plan to pay for the inpatient hospital services at the DRG 637 payment level. You say that you would like reconsideration because the documentation supports DRG 637. The Plan denied your request. The Plan says that according to coding guidelines and documentation in the medical record metabolic encephalopathy and acute on chronic systolic congestive heart failure do not qualify for reporting.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records. The Plan has not forwarded any clinical documentation. We are unable to verify if criteria have been met for the billing of DRG 637. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on February 6, 2020, through February 10, 2020 at the Diagnosis Related Group (DRG) 637 payment level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth individual mental health
session (99214) rendered on June 2, 2021.
You asked the Plan to waive the copayment for a telehealth individual mental health visit. You say that the
services should be covered because you were not getting the medical help you needed from that office. The
Plan denied your request. The Plan says you have been charged the correct copayment 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 telehealth individual
mental health sessions are covered, however, you must pay a $35 copayment for each individual mental health
session.
You have been asked to pay a $35 copayment for a telehealth individual mental health session. Telehealth
individual mental health sessions fall within the Physician/Practitioner Services, Including Doctor's Office
Visits benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a telehealth individual mental
health session (99214) rendered on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction received on July 21, 2021.
You asked the Plan to pay for the refraction. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction vision services. The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does not have to pay for an eye refraction received on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you feel this service should be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 office visit provided on May 19, 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for surgical management of cancer of the mandible and for a tracheostomy. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure, NSTEMI, and coronary artery bypass grafting. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not currently treated with insulin.
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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on June 30, 2021.
You asked the Plan to pay for the ambulance service. You say that you have a family history of strokes. You
say that you were experiencing extreme back pain and cold sweats. You say that this should be paid. You also
say that this was medically necessary. The Plan denied your request. The Plan says no transport was provided
and therefore there is no coverage.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 30, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport, (A0998) provided on June 30, 2021.