Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471), reduction of osseous tuberosity (D7485), first 15 minutes of deep sedation/general anesthesia (D9222), two subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x2), and therapeutic parenteral drugs (D9612).
You asked the Plan to pre-approve the removal of lateral exostosis, reduction of osseous tuberosity, deep sedation/general anesthesia, and therapeutic parenteral drugs. The Plan denied your request. The Plan says these services are 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. 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 pre-approve a removal of lateral exostosis (D7471), reduction of osseous tuberosity (D7485), first 15 minutes of deep sedation/general anesthesia (D9222), two subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x2), and therapeutic parenteral drugs (D9612).
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), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635).

You asked the Plan to pre-approve the service. You say that you are in debilitating pain, you tried acupuncture
and CBD oil that has not worked. You state that you had one ablation, but you need the second one to
determine how to address your pain. The Plan denied your request. The Plan says your request is not medically
necessary because the records indicate that you have had only one diagnostic injection.

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 service. Our physician reviewer
found there is no documentation provided indicating the prior injection provided pain relief for at least three (3)
months. The review has determined that you do not meet the coverage criteria detailed in the LCD. There is no
specific clinical rationale for the requested facet joint injections.

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 service 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), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635).
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 you cannot go home at this time and you cannot go to a skilled nursing facility due to COVID concerns. IRF care is necessary for your recovery. The Plan denied your request. The Plan says criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in 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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 

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 continuation of acute inpatient rehabilitation facility
(IRF) services beyond September 25, 2021.

You asked the Plan to pre-approve continued IRF care. You say that continued IRF care is medically necessary
for this enrollee and the necessary services cannot be provided at a lower level of care. The Plan denied your
request. The Plan says the enrollee no longer requires IRF care. The enrollee has made significant improvement
and does not appear to require an intensive program to return to baseline. Continued care can be provided in an
alternate setting.

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 continued 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 that the complexity of the enrollee's nursing, medical and
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. While the documentation does support a need for physical and/or occupational therapy,
there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued IRF care have not been met. Therefore, we decided that the Plan does
not have to pre-approve continuation of acute inpatient rehabilitation facility (IRF) services beyond September
25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided from March 18, 2021, to April 1, 2021.

You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that you disagree with the charges because you should only owe a $10 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 50% coinsurance for out-of-network outpatient rehabilitation services provided in an outpatient hospital facility. The record shows that you received out-of-network outpatient rehabilitation services at an outpatient hospital facility on March 18, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $71.01 and 50% of that is $35.50.

The total amount you owe is: $71.

You have been asked to pay the total coinsurance amount of $71 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 coinsurance for outpatient rehabilitation services provided from March 18, 2021, to April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient services you received from May 12, 2021, to May 16, 2021, and May 20, 2021, to June 3, 2021.
You asked the Plan to waive the copayments for the two inpatient admissions. You say that you don't think you should have to pay multiple copayments for the same thing. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per admission for inpatient hospital care. Records show that you were admitted to an inpatient rehabilitation facility from May 12, 2021, to May 16, 2021. You were then discharged. You were readmitted to the inpatient facility from May 20, 2021, to June 3,
2021. You have been asked to pay a $295 copayment per admission for each of these admissions. According to your contract, you pay this copayment each time you are admitted. 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 copayments for inpatient services you received from May 12, 2021, to May 16, 2021, and May 20, 2021, to June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 14 and 16, and a
pontic (D6241) for tooth # 15.
You asked the Plan to pre-approve the dental services. You say that you need a bridge. You also say that you
only have 1 tooth at the front. The Plan denied your request. The Plan says retainer crowns are not listed as
covered services. The Plan also says that pontic is not listed as a covered service either.
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 retainer crowns and
pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve retainer crowns (D6751) for teeth # 14 and 16, and a pontic (D6241) for tooth # 15.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on April 23, 2021, to June 4, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that these are all post-op visits, and they should be covered fully. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $40 copayment for outpatient diagnostic tests/basic radiological services/specialist. You have been asked to pay a $40 copayment for each x-ray. The total amount you are being asked to pay is $80 ($40 x 2 x-rays = $80). Post-operative services are subject to the correct copayment amount; therefore, the correct copayments have been applied. An x-ray falls within the outpatient diagnostic tests/basic radiological services/specialist 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 x-ray provided by a participating provider on April 23, 2021, to June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met and stabilized in the acute care setting, and the enrollee is stable to transfer to an LTACH for continuation of care. The Plan denied your request. The Plan says the criteria for a transfer and admission to an LTACH has not been met.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee require does not services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the saline flushes, sterile water, saline and/or dextrose,
diluent/flush, 10 ml (A4216).
You asked the Plan to pre-approve the saline flushes. You say that the enrollee has prostate cancer needs the
saline to get his foley catheter flushed daily to prevent blood clots. The Plan denied your request. The Plan says
the criteria has not been met as this item is not covered when used for irrigation of a foley catheter.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
In this case, the provider indicated that the saline flush would be used for irrigation of your catheter and not for
used of a nebulizer or suction pump. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the saline flushes have not been met. Therefore, we decided that
the Plan does not have to pre-approve the saline flushes, sterile water, saline and/or dextrose, diluent/flush, 10
ml (A4216).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair.

You asked the Plan to pre-approve these services. You say that you have difficulty walking. The Plan denied
your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. The rules say that an extra heavy-duty wheelchair (K0007) is covered if
the beneficiary weighs more than 300 pounds.

We looked at the file and Medicare rules. The file shows that you do not weigh more than 300 pounds. Based
on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on April 22, 2021.

You asked the Plan to pay for the services. You say that an in-network provider requested these services, and the codes used are established and correct for the reporting of molecular pathology procedures. The Plan denied your request. The Plan says this service was not supported by the procedure codes billed on the claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a pulmonologist on April 15, 2021.

You asked the Plan to waive the copayment for the pulmonology visit. You say that this copayment should be waived because it was related to the Coronavirus (COVID-19). The Plan denied your request. The Plan says you were charged this copayment correctly because there is no evidence that this visit was related to COVID-19.

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 $30 copayment for visits with a specialist. 

You have been asked to pay a $30 copayment for the pulmonology visit. The billing records from this office visit show that you were seen for mild persistent asthma, not for COVID-19. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had with a pulmonologist on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on May 11, 2021.

You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like reconsideration because this testing is a medically necessary Medicare covered benefit. The Plan denied your request. The Plan says two or more diagnosis codes on the submitted claim are mismatched.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 0242U is not supported in the record. Specifically, the laterality of the diagnosis codes on the claim are mismatched. The claim includes codes for both right and unspecified sides. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an outpatient surgery and a
specialist office visit provided by a participating provider on June 17, 2021.
You asked the Plan to waive the deductible and copayment for an outpatient surgery and a specialist office
visit. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct
deductible and copayment have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible. There is a $35 copayment which applies to
physician/practitioner services/specialist in-person.
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit
category physician/practitioner services/specialist in-person and outpatient surgery. The Plan has followed
Medicare rules by clearly disclosing in the contract that there is a $750 deductible and a $35 copayment which
applies to physician/practitioner services/specialist in-person. You have been asked to pay $325.63 for an
outpatient surgery and a $35 copayment for a specialist office visit. The total amount you are being asked to
pay is $360.63 ($325.63 + $35 = $360.63). This cost sharing is a contractual obligation that had not been met at
the time an outpatient surgery and a specialist office visit was received on June 17, 2021. Therefore, we
decided that the Plan does not have to waive the deductible for an outpatient surgery and copayment for a
specialist office visit provided by a participating provider on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts.

You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. 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 pre-approve shoe inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four custom fabricated abutments (D6057 x4).
You asked the Plan to pre-approve the custom fabricated abutments. You say that you need these screws to
attach to your denture because the denture does not work without the screws. The Plan denied your request.
The Plan says this service is not covered under your benefit plan.
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 pre-approve four
custom fabricated abutments (D6057 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve an outpatient surgery. You say that this is the only doctor that specializes in
this specific type of surgery. The Plan denied your request. The Plan says there are in-network physicians
available to provide these services.

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
an outpatient surgery to be provided by an out-of-network (OON) provider.