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

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON orthopedic services. You say that the enrollee has severe pain in both right and left knees. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers who are within a reasonable distance of the enrollee's location that can provide the services needed.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (EEG) (95822) provided on March 5, 2021.
You asked the Plan to pay for EEG 95822. You say that denial of this claim is not justified. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 95822 has a procedure-to-procedure (PTP) edit of 1 with code 51785 so cannot be separately paid without an appropriate modifier.
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, we have confirmed that code EEG 95822 is a column II code to column I code 51785. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (EEG) (95822) provided on March 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional physical therapy (PT) visits (97110).
You asked the Plan to pre-approve additional PT visits. You say that the enrollee has demonstrated great adherence to PT and home exercise. You are also requesting approval because it is unsafe to manage progressions of ability at home, as the enrollee has undergone BLE amputation which has an exacerbation of concerns and impairments due to inactivity. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional physical therapy (PT) visits (97110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Breztri Aerosphere.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Breztri Aerosphere.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further for the root canal, cleaning, crown, and core buildup rendered on July 15, 2021 to August 9, 2021.
You asked the Plan to pay further for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was processed correctly.
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 says that enrollees pay 0% for a cleaning from an in-network provider and 70% for a crown from an in-network provider. The Plan does not cover core buildup or root canals. We looked at the file and the Plan's rules. The file shows that you received services from an out-of-network provider; however, the Plan agreed to process the claim at the in-network level as a one-time exception. You have been asked to pay 0% for the cleaning and 70% of the total cost for the crown. The core buildup and root canal are not covered benefits. Therefore, we decided that the Plan does not have to pay further for the root canal, cleaning, crown, and core buildup rendered on July 15, 2021 to August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's rehabilitation needs do not require an interdisciplinary team approach to the delivery of rehabilitation 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 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 shoulder replacement surgery. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 11, 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 procedure code 63048 is not supported.
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 63048 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure). We find that CPT code 63048 is not supported in the medical record. Specifically, there is no documentation of a single vertebral segment, laminectomy, facetectomy and foraminotomy, for each additional segment. 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 pay for the surgical services rendered on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided on April 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were not pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on April 12, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313) and ankle support feature (K0108).
You asked the Plan to pre-approve the expandable controller and ankle support feature. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that an expandable controller is subject to the criteria listed in the Medicare rules section. The ankle support equipment 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. It appears to be primarily for the enrollee's comfort. 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 an expandable controller. Our reviewer says that the expandable controller is not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the expandable controller meets Medicare criteria for medically necessary to accommodate proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)/ non-proportional input devices (e.g., sip and puff, head array, etc.)/ to operate 3 or more powered seating actuators/ to operate a separate display/ other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)/ or an Attendant Control. Records document that the enrollee has 4/5 right upper extremity strength and right upper extremity range of motion within functional limits, thus indicating she has adequate right upper extremity strength and function to control the wheelchair's power options with their own switches. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313) and ankle support feature (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 7, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy provided on April 22, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that you have this procedure done every six months, and you only pay $250 for the doctor's copayment. You say there is no $40 copayment. 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 when you have outpatient surgery, there may be a separate cost share for physician services. Your contract also says that you must pay a $40 copayment per visit for specialist physician services. You have been asked to pay a $40 copayment per visit for the specialist physician services for the endoscopy.
Specialist physician services fall 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 an endoscopy provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88342) rendered by the
out-of-network (OON) provider on July 22, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services (88305, 88342) rendered by the out-of-network (OON)
provider on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis services.
You asked the Plan to pre-approve the requested services. You say that you have pain and issues with eating. The Plan denied your request. The Plan says this procedure is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of torus mandibularis 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.
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 do not meet all the required Medicare criteria for admission to an Inpatient Rehabilitation Facility.
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 weakness, decreased mobility, and a urinary tract infection. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided May 12, 2021 to July 8, 2021.
You asked the Plan to pay for the chiropractic services. You say that your benefit Plan states that chiropractic services are covered with a $20 copayment. You don't understand why these claims re being denied when you have continually been told by member services that this is a covered benefit. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided May 12, 2021 to July 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided September 25, 2019 to October 3, 2019.
You asked the Plan to pay for the inpatient care. You say that DRG 854 was correctly billed. The Plan denied your request. The Plan says DRG 661 more accurately describes the services at issue.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 854. 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 the inpatient care. Our reviewer says that DRG 854 is not supported. Our physician reviewer found review indicates that the documentation supported an admission for pyonephrosis. The documentation was unclear regarding a diagnosis of sepsis. While severe sepsis was documented on progress notes and the discharge summary, supporting medical record documentation was not found within the record. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided September 25, 2019 to October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from February 22, 2021, to March 6, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are trying to get medigap insurance to cover the balance. 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 $500 per day for days 1-7 of out-of-network inpatient hospital care and $0 per day after day 7. The records shows you were in the hospital from February 22, 2021, to March 6, 2021. You have been asked to
pay $500 per day for the first seven days of out-of-network inpatient hospital care. The total for your stay is $3500. Inpatient hospital 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 hospital services provided from February 22, 2021, to March 6, 2021.