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

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says based on the current level of function, there has been no change in function that needs daily skilled therapy or nursing.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not qualify for SNF coverage, as you do not have any documented skilled nursing or skilled therapy needs. You are ambulating household distances, and tending to activities of daily living with minimal supervision. Your care needs, as a practical matter, could be provided at a lower level of care, such as home, assisted living, or long term 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction services provided on June 28, 2021.  You asked the Plan to pay for the refraction services. You say that this service has always been covered. The Plan denied your request. The Plan says the claim was processed correctly.   Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The records show that you received a diabetic eye exam. Refraction services are only covered when they are part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept Procedure.  You asked the Plan to pre-approve Intracept Procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. The intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept Procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), intraoral complete series (D0120), and prophylaxis (D1110), provided on June 23, 2021.  You asked the Plan to pre-approve the comprehensive oral evaluation, intraoral complete series, and prophylaxis. You say that the services should be covered. The Plan denied your request. The Plan says you obtained these services through an out-of-network provider.  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, you received care from an out-of-network provider. This means the services are not covered. Therefore, we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), intraoral complete series (D0120), and prophylaxis (D1110), provided on June 23, 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant360 testing rendered on July 20, 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 were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that Guardant260 testing was covered when specific criteria are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has newly-diagnosed stage IV adenocarcinoma of the lung with bilateral disease. It has not been documented that tissue-based comprehensive genomic profiling is infeasible. The documentation is insufficient to demonstrate the Graudant350 testing was medically reasonable and necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on July 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 28, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that the nurse at your doctor's office told you to call the ambulance to check on your condition due to being diagnosed with Coronavirus. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.  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 28, 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 ambulance response and treatment, no transport (A0998) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the disposable contact lenses (S0500) purchased on August 3, 2021. You asked the Plan to pay for the contact lenses. You say that you have not used this benefit this year and do not understand why these services are denied. The Plan denied your request. The Plan says you previously purchased contact lenses on March 19, 2021. This benefit may only be used once per year.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $300 for one purchase per year.  We looked at the file and the Plan's rules. Documentation shows that you previously purchased disposable contacts in March of 2021 and used your benefit at that time. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the disposable contact lenses (S0500) purchased on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service (A0428), provided on June 25, 2021.  You asked the Plan to waive the copayment for the ambulance service. 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 $250 copayment for ambulance services.   You have been asked to pay $237.25 out of the $250 copayment for the ambulance service. This service falls within the ambulance 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 ambulance service (A0428), provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an anesthetic injection (64415-59) and special anesthesia services (99100) provided on February 9, 2021.  You asked the Plan to pay for an anesthetic injection and special anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The rules also say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the submitted records consist of a single page of an anesthesia record. There is no documentation of an anesthetic injection occurring in a different encounter, procedure, or site. Based on this information, we decided that Medicare rules for coverage of 64415 billed with a -59 modifier have not been met. Code 99100 has a status indicator of B and cannot be paid separately from other services. Therefore, we decided that the Plan does not have to pay for an anesthetic injection (64415-59) and special anesthesia services (99100) provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions (D7140) provided on May 26, 2021.  You asked the Plan to pay for the extractions. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied 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.  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, you obtained these services out-of-network and exceeded the allowed amount for this service. Therefore, we decided that the Plan does not have to pay for the extractions (D7140) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 20, 2021.  You asked the Plan to pay for the limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says this is not 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, the requested items or services are not among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered.      Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to hold you harmless for the stem cell treatment (Q4233) and arthrocentesis (20611) provided on May 8, 2021.  You asked the Plan to hold you harmless for the stem cell treatment and arthrocentesis. You say that you would like reconsideration because this treatment was recommended by your primary care physician. The Plan denied your request. The Plan says that this procedure is considered investigational but you are not liable for payment beyond the applicable cost share.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the stem cell treatment and arthrocentesis by a contract provider. The file does not show that the Plan provided notice that the stem cell treatment and arthrocentesis would not be covered. Under Medicare rules, this means the stem cell treatment and arthrocentesis is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the stem cell treatment (Q4233) and arthrocentesis (20611) provided on May 8, 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: 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 clinical information provided supports the need for care in an IRF. The Plan denied your request. The Plan says the medical records do not show that the enrollee needs an intensive program with a team of health care professionals and doctors that specialize in rehabilitation.  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 at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PMR) physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing care needs. Based upon the enrollee's current high level of function, pain limiting participation as described above, she does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee needs physical therapy and occupational therapy in an alternate and low intensity level. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF.)  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 pre-approve the psychotherapy services (90849) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the psychotherapy services. You say that you are requesting to see a psychologist closer to where you live. You want an in-person visit and the referrals you have received were for practitioners that were 27 miles away or more. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the psychotherapy services (90849) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Coflex device.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the problem.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this device is experimental. More research is needed to show safety and efficacy of the device.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 31.  You asked the Plan to pre-approve the crown. You say that you need the crown because you want to prevent your tooth from cracking completely. The Plan denied your request. The Plan says tooth # 31 does not show large decay requiring replacing a significant amount of the tooth, and photographic and x-ray images show little decay, which can be restored with a conventional filling. The Plan also says that this condition does not meet the required clinical criteria to establish medical necessity.  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 the crown when the services are medically necessary and reasonable.   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 crown. Our reviewer says that the crown is not medically reasonable and necessary. Our physician reviewer found the provided x-rays show an essentially intact tooth with no noted breakdown from caries or fracture. In general, crowns re considered where there is extensive breakdown of tooth structure, usually in the order of 50%. Our reviewer found that the tooth in question clearly does not have any significant loss of structure, and any defect that may exist on it should be restorable with conventional materials and not require cutting the entire tooth to fit a full coverage crown. Our physician reviewer also found that without any additional information it cannot be found that tooth # 31 requires a full coverage crown in this instance.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 31.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on May 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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 70450 is a column II code to column I code 70496. 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 the services (70450) provided on May 30, 2020.