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

 We decided that the Plan does not have to pay for laboratory services (80048, 80076, 85025) provided on June 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you would like for the Plan to reconsider the denial for coverage so that the member can continue care with their established provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 laboratory services (80048, 80076, 85025) provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the body movement therapy (97140), provided on August 18, 2021.  You asked the Plan to waive the copayment for the body movement therapy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $10 physical therapy copay for outpatient rehabilitation services.   You have been asked to pay a $10 physical therapy copay for the body movement therapy. This service falls 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 copayment for the body movement therapy (97140), provided on August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) services provided from July 1, 2020, to July 30, 2020, by an OON provider.  You asked the Plan to pay for the SNF services. You say that you were not aware that the enrollee enrolled with another plan while they were in your facility, and it was impossible to obtain pre-authorization for these services. The Plan denied your request. The Plan says the services were not pre-certified.    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 does cover OON SNF care, but authorization is required. 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 inpatient skilled nursing facility (SNF) services provided from July 1, 2020, to July 30, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 23, 20921, through July 29, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $335 copayment each day one through 6 for inpatient hospital care.   You have been asked to pay a $335 copayment each day one through 6 for the inpatient hospital care. This service falls 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 the inpatient hospital care provided on July 23, 20921, through July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on May 3, 2021.  You asked the Plan to pay for the services provided. You say that the medical records support the claim. The Plan denied your request. The Plan says no separate payment is made per Medicare.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on May 3, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the CYP2C19 testing provided on April 10, 2021.  You asked the Plan to pay for the CYP2C19 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that this code has not met the associated diagnosis code relationship criteria.  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. Review of the file shows that the Plan uses Local Coverage Determination (LCD), L35062 and Local Coverage Article (LCA) A56541 to support their denial. However, LCD L35062 and LCA A56541 are not valid for the provider's billing state of Ohio. This means we are unable to use these documents to substantiate our decision. In addition, the Plan states that these services billed have not met the associated diagnosis code relationship criteria. However, the correct Local Coverage Determination (LCD) L38394 for the provider's billing state of Ohio does not list specific diagnosis codes that must be billed in order for this service to be covered. Since a valid argument was not provided, this means the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the CYP2C19 testing provided on April 10, 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: Unfavorable

 We decided that the Plan does not have to pre-approve the implant supported porcelain/ceramic crown (D6065), and abutment supported porcelain/ceramic crown (D6058), provided on September 23, 2021.  You asked the Plan to pre-approve the implant supported porcelain/ceramic crown and abutment supported porcelain/ceramic crown. You say that the services were medically necessary. The Plan denied your request. The Plan says the member exceeded their limit two per one 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.  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. Specifically, the records indicate you have already utilized the maximum allowance for this benefit. Therefore, we decided that the Plan does not have to pre-approve the implant supported porcelain/ceramic crown (D6065), and abutment supported porcelain/ceramic crown (D6058), provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and non-intravenous conscious sedation (D9248) provided on September 9, 2021.    You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and non-intravenous conscious sedation. You say that the Plan you have under additional services includes preventive services, but this is not defined anywhere. You also think that the x-ray taken should be considered preventive, and the extraction should be covered under oral surgery. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and non-intravenous conscious sedation (D9248) provided on September 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 (CPT code(s): 81432) and hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 (CPT code 81433), for the enrollee.
You asked the Plan to pre-approve the laboratory services. You say that this testing is medically necessary given the enrollee's significant family history of cancer and this testing will be used to determine plan of care and guide treatment options. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 laboratory services. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the requirements listed in the LCD: MolDX: BRCA1 and BRCA2 Genetic Testing (L36161) for Medicare coverage for the requested testing. Records do not document the enrollee has breast cancer and a family history of a known deleterious BRCA1 or BRCA2 gene mutation. Records do not document the enrollee's breast cancer diagnosis meets any of the criteria. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 (CPT code(s): 81432) and hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 (CPT code 81433), for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Qvar Redihaler.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 a Qvar Redihaler.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (CPT code 64454) provided to the enrollee on July 1, 2021.

You asked the Plan to pay for the services. You say that the service was medically necessary for the pain management treatment. The Plan denied your request. The Plan says the service is considered experimental and investigational.

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 pay for the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this was an experimental/ investigational procedure. Therefore, the procedure was not medically reasonable and necessary. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (CPT code 64454) provided to the enrollee on July 1, 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 you need physical therapy to rebuild strength and to get back to her normal functioning ability. You say that you were residing in a FEMA trailer due to a natural disaster where you would not now be able to receive therapy. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in another 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 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 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. The enrollee was admitted for scheduled cervical spine surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has 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 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on March 13,
2021 to May 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that you would like
reconsideration because you were not able to wait for the services of a network provider. The Plan denied your
request. The Plan says there are network providers available who are able to render your necessary care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider at issue in this case is not a network provider with the Plan. 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 outpatient mental health services. Our reviewer says that the records
provided show that you did not require treatment by an out-of-network provider as the medical Plan is able to
provide a psychotherapist for the treatment of your condition. Our physician reviewer found your condition is
not considered urgent/emergent. Utilization of a network providers assures a credentialed and clinically
maintained individual assured by the medical provider to a certain standard of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the outpatient mental health services have not been met.
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 pay for the outpatient mental health services. Therefore, we decided
that the Plan does not have to pay for the outpatient mental health services provided on March 13, 2021 to May
26, 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 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 the enrollee can be treated at a lower level of care, such as at home with home health or at a skilled nursing 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. Our physician reviewer found 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. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility based on their limited endurance as reported in the records. Care at the skilled nursing facility level appears to be appropriate in this case.  

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 Cabergoline.

You asked the Plan to pre-approve Cabergoline. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.

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 Cabergoline.

Benefits for Cabergoline 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: 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary. 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 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 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.
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.