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

We decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT) code 62323, for the enrollee.
You asked the Plan to pre-approve the injection. You say that the treatment is medically necessary for the enrollee to get pain relief. The Plan denied your request. The Plan says the notes show that the injection in the past did not help the enrollee's pain. The Plan states the notes also do not show that the enrollee's doctor will use a different approach, level and/or steroid for this 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 injection. Our physician reviewer found the LCD criteria for a repeat ESI is greater than 50% pain relief for three (3) months. This time period has not passed yet and there is NO role for a series of blocks. Therefore, the request is deemed not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT) code 62323, for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) magnetic resonance (eg, proton) imaging, spinal canal and contents (72158) radiologic examination, spine, lumbosacral (72100) injection, gadobutrol (A9585) provided on July 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient clinic visit. You say that the MRI was medically necessary due to spinal fusion, lumbosacral follow up. 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 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 hospital outpatient clinic visit (G0463) magnetic resonance (eg, proton) imaging, spinal canal and contents (72158) radiologic examination, spine, lumbosacral (72100) injection, gadobutrol (A9585) provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be submitted to the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on June 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (G0299), HH physical therapy (PT) (G0151), HH occupational therapy (OT)(G0152), and HH speech therapy (ST)(G0153).
You asked the Plan to pre-approve the home health skilled nursing, PT, OT, and ST services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health skilled nursing, PT, OT, and ST services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 home health skilled nursing, PT, OT, and ST services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (G0299), HH physical therapy (PT) (G0151), HH occupational therapy (OT)(G0152), and HH speech therapy (ST)(G0153).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 1, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an exercise bike purchased on January 12, 2021.
You asked the Plan to reimburse you for the exercise bike. You say that you need to use at home equipment
due to risk of going to a gym as you did not consider it a safe environment. You say that you did attempt to go
to the gym but did not feel that the other members were being safe enough with mask use, and you were not
made aware of the Plan's temporary Coronavirus benefit ending on December 31, 2020. The Plan denied your
request. The Plan says exercise bikes are not covered under your Plan's Wellness Allowance benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met because an exercise bike is not a covered
benefit. Therefore, we decided that the Plan does not have to reimburse you for an exercise bike purchased on
January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopantogram (e.g. panoramic x-ray) (70355) unlisted dental procedure code (41899) provided August 9, 2021
You asked the Plan to pay for the dental services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The health Plan contract says that an authorization is required for non-emergency Medicare covered dental services. Routine dental care such as cleanings, fillings, or dentures are not covered. Non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care. You can find this information on pages 43 and 64-65 of the Plan's 2021 Evidence of Coverage. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for orthopantogram (e.g. panoramic x-ray) (70355) unlisted dental procedure code (41899) provided August 9, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 22, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
genetic testing provided on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on September 10, 2021.
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 70544 is a column II code to column I code 70551. 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 imaging services provided on September 10, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the hospital services provided from
September 3, 2021, through September 11, 2021.
You asked the Plan to waive the cost sharing for the hospital services. You say that you would like
reconsideration of the hospital bill submitted for review. The Plan denied your request. The Plan says the cost
share has been 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for Emergency Care.
The enrollee has been asked to pay a $90 copayment for the hospital services. The hospital services fall within
the Emergency Care benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan.
Additionally, the claim lines for self-administered drugs have been denied because self-administered drugs are
not covered under Medicare Part B. The enrollee has been held liable for the cost of their copayment for
emergency services and the cost of the self-administered drugs totaling $194.80. Please contact the Plan if you
are being asked to pay more than the contracted amount with the Plan. Therefore, we decided that the Plan does
not have to waive the cost sharing for the hospital services provided from September 3, 2021, through
September 11, 2021.
Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425) provided on July 20, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says that the enrollee's claims history indicates they were in an inpatient hospital status on this date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is considered part of the inpatient admission, and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is
considered "patient transportation" and is covered as an inpatient hospital service. We looked at the file and the Medicare rules. In this case, the documentation has determined the enrollee was transported to another facility temporarily for care. This is not separately payable from the inpatient services according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, porcelain/ceramic substrate (D2740) provided September 14, 2021.

You asked the Plan to pay for the dental service. You say that you were told that the dentist was in-network and the crown might have been denied for being cosmetic. The Plan denied your request. The Plan says this service is not covered under the Plan benefits

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 health Plan contract specifically says that any services not listed is not covered. This service is not listed and is therefore not covered. 

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 crown, porcelain/ceramic substrate (D2740) provided September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care items (A4450, A6023, A6446 and A6450) provided on February 11, 2021.

You asked the Plan to pay for the wound care items. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is missing information required for payment.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the items at issue in this claim. Specifically, the proof
of deliver that was submitted is not for the date of service of February 11, 2021. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wound care items (A4450, A6023, A6446 and A6450) provided on February 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) individual psychotherapy
(90833) provided on August 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are appealing the denial for payment. The
enrollee was seen at your office and let their referral run out. You got those updated on September 1, 2021. 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) individual
psychotherapy (90833) provided on August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pathology consultation during surgery (88334) provided on February 24, 2021.
You asked the Plan to pay for code 88334. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88334 is an add-on code and has not been billed with an appropriate primary procedure code. 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 Pathology consultation during surgery (88334) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified maxillofacial prosthesis, by report (D5999) unspecified preventive procedure, by report (D1999) provided September 30, 2021.
You asked the Plan to pay for the dental services. You say that you are trying to keep a normal lifestyle and stay active and this oral apparatus will help you do this. Please reconsider this decision. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.
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 unspecified maxillofacial prosthesis, by report (D5999) unspecified preventive procedure, by report (D1999) provided September 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 1, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are not payable.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says criteria for admission to the LTACH have not been met. The Plan states the
enrollee's medical needs are being met in the current acute setting. The Plan states LTACH would add no
additional services and with additional time in the current setting, clinical stability can be ensured such that the
appropriate lower level of care can be determined.
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 appears to be improving and only requires short-term additional acute
care services that can be safely administered at the current facility. The enrollee does not require services at the
LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be
considered soon when treatment has completed.
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 LTACH services.