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

We decided that the Plan does not have to pay for a PET-CT scan from skull-base to mid-thigh (78815) provided on April 18, 2021.
You asked the Plan to pay for a PET-CT scan. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for PET scans have not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are only covered for specified diagnosis codes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET-CT scan have not been met. Specifically, the diagnosis codes provided, C50.919 breast cancer of unspecified site and C79.51 secondary cancer of bone, are not among the eligible diagnosis codes listed in the Medicare rules. Therefore, we decided that the Plan does not have to pay for a PET-CT scan from skull-base to mid-thigh (78815) provided on April 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cognitive assessment and care plan services (99483)
provided on March 16, 2021, by an OON provider.
You asked the Plan to pay for the cognitive assessment and care plan services. You say that your physician
provided medically necessary services to the enrollee in good faith. In consideration for the services rendered,
your doctor is seeking reimbursement. 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. Nonemergent
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. The records also show the Plan made several attempts to obtain medical records from the
provider without success. 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 cognitive assessment and care plan services
(99483) provided on March 16, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
for the enrollee.

You asked the Plan to pre-approve a CGM. You say that the enrollee has neuropathy, and this condition has
made the process of traditional finger prick glucose testing difficult and painful. The Plan denied your request.
The Plan says that the enrollee does not use insulin at least three times a day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre
continuous glucose monitor (CGM) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330) and bitewing x-ray (D0272) provided on March 15, 2021.
You asked the Plan to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330) and bitewing x-ray (D0272). You say that the office contacted the Plan to confirm coverage and the services were authorized before they were rendered. You say that you are not in a position to pay this high amount and are appealing the denial of payment of $347. The Plan denied your request. The Plan says that reimbursement has already been issued for a comprehensive oral evaluation, bitewing x-rays and panoramic x-ray.
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, you also have a maximum benefit of one comprehensive oral evaluation and panoramic x-ray every three plan years and one bitewing x-ray every plan year. The Plan paid for the comprehensive oral evaluation and panoramic x-ray provided on October 14, 2020. The Plan also paid for one of the bitewing x-rays provided on March 15, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330) and bitewing x-ray (D0272) provided on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on June 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 surgical pathology services provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90832) provided on February 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the individual psychotherapy. You say that you totally disagree with the denial because the provider had been your psychiatrist for a while, and you did not need a referral to see her. 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 individual psychotherapy (90832) provided on February 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on April 27, 2021.

You asked the Plan to waive the copayment for a spinal canal injection. You say that the injections improve your quality of life but you cannot afford the high copayment and request that the Plan reduce the cost-sharing charges. 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 a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

The record shows that you received a spinal canal injection at an outpatient hospital facility on April 27, 2021. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. 

You have been asked to pay a $250 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a spinal canal injection provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on October 13, 2020.
You asked the Plan to pay for the resin-based composites. You say that you have been going to this dental office for several years because they are one of the few that accepts your plan. You say that they didn't let you know your benefits were exceeded. The Plan denied your request. The Plan says reimbursement has already been issued for two fillings.
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, you also have a maximum benefit of two amalgam or resin-based composites per calendar year. The Plan paid for two resin-based composites provided on September 22, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurosurgery office visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visits. You say that you need to get in to see your doctor as soon as possible so you can carry on with the procedure that you need. The Plan denied your request. The Plan says there is not a gap issue and there are in-network providers available who can supply the requested 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 neurosurgery office visits to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on April 9, 2021.
You asked the Plan to waive the copayment for colonoscopy. You say that you were diagnosed with minor symptoms a while back and were told if they did not go away you would have a colonoscopy, so this was nothing more than a routine screening. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $325 copayment for diagnostic colonoscopy. This colonoscopy was provided due to a non-routine indication, so it is considered to be a surgical service and not a screening or preventive service. You have been asked to pay $325 copayment for colonoscopy. Colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on April 9, 2021.
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.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a seizure and had resection of a cranial meningioma. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

While 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. You say that this provider has the necessary equipment to support the enrollee. The Plan denied your request. The Plan says there are in-network providers capable of servicing the enrollee's needs. The Plan states the services are not medically necessary from an out-of-network provider.
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 physical therapy services to be provided by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for oncology.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network oncologists available.

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 out-of-network referral for oncology.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (E1161) and accessories.
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (E1161) and accessories.
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 enrollee will clearly benefit from acute rehabilitation to optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation
services (A0428, A0425) provided on June 27, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you wanted transportation
by Lyft but when you were brought out, there was an ambulance waiting for you and you were told it was
covered by your insurance. The Plan denied your request. The Plan says the ambulance is covered, but you are
responsible for your share of the cost. Each Medicare-covered one-way ambulance trip requires a $222
copayment. This claim was processed 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 $222
copayment for ambulance services.
You have been asked to pay a $222 copayment for the ambulance transportation. 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 non-emergent ambulance transportation services (A0428, A0425) provided on
June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that you had surgery at the same facility about four
years ago. The Plan denied your request. The Plan says the services are available from network providers.
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
a referral to an out-of-network orthopedic surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the gallbladder removal provided on April 23, 2021 billed with code 47562.
You asked the Plan to pay for the gallbladder removal. You say that this was denied as duplicate in error. The Plan denied your request. The Plan says the same service was paid to this surgeon through a different billing entity. This service is not able to be provided twice, meaning that only one payment is possible.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 47562 is 1. The MAI value for this code is 2. One unit of this code was paid on a claim submitted by a different billing entity. As one unit is paid, the denied claim is appropriate. Based on this information, we decided that Medicare rules for coverage of the gallbladder removal have not been met. Therefore, we decided that the Plan does not have to pay for the gallbladder removal provided on April 23, 2021 billed with code 47562.