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

 We decided that the Plan does not have to pre-approve a specialist office visit (99203, 99213) to be provided by an OON provider.  You asked the Plan to pre-approve a specialist office visit. You say that the doctor you are requesting is a specialist and was recommended. The Plan denied your request. The Plan says the request is not urgent, and this service is offered in the main network. The Plan also says that you have been approved for this service with a provider in-network.  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 specialist office visit (99203, 99213) to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pain management injection services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve pain management injection services. You say that it is medically necessary for you to receive these services from the OON provider you are familiar with. The Plan denied your request. The Plan says they have multiple in-network providers available to handle your medical care needs.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 pain management injection services. Our reviewer says that it is not medically necessary for you to continue receiving care from an out-of-network (OON) provider. Our physician reviewer found that the reviewed documentation indicates that you are a 56-year-old female with a history of chronic pain syndrome due to post-laminectomy syndrome, cervical radiculopathy, thoracic and lumbar back pain. You have been treated with medical therapy including opiates. You are currently followed by an OON pain management specialist who has recommended injection therapy. The review has determined that there is no specific medical indication for OON services. Your care can be managed by an in-network pain management specialist. It is not medically necessary for you to continue receiving care from the OON provider, with regard to the requested pain management injections.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pain management injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve pain management injection services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Lorazepam tablet.  You asked the Plan to pre-approve Lorazepam tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Lorazepam tablet.   Benefits for Lorazepam tablet 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that the provider charged you for a comprehensive exam but only performed a routine exam and basic cleaning. You also say that you did not receive a comprehensive exam during the pandemic. The Plan denied your request. The Plan says this procedure exceeds the frequency limitations under your 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, comprehensive oral exam (D0150) is covered once every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on October 1, 2020, and your comprehensive oral exam (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 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 IRF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  

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 IRF case is not medically necessary based on a lack of medical complexity, rehabilitation nursing needs, and slow progress. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be met at a lower intensity setting such as a skilled nursing facility.  

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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the psychosocial rehabilitation services, per 15 minutes (H2017) provided on October 19, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization.  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.  The case file provided to our organization indicates that the enrollee was referred for these services by a contract provider. The file does not show that the plan provided notice that these services would not be covered. Under Medicare rules, this means that the services provided are considered approved by the plan. Therefore, we decided that the Plan has to pay for the psychosocial rehabilitation services, per 15 minutes (H2017) provided on October 19, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Accu-check blood glucose (sugar) test strips (CPT code A4253NU).  You asked the Plan to pre-approve the services. You say that the strips are medically necessary based on type 1 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the other strips, that are covered by the plan will work with your pump.  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 clinical information that we received indicates that the supplies requested are for use with your Medtronic insulin pump for treatment of type I diabetes mellitus. A Medtronic representative has advised the plan's medical director that other strips, that are covered by the plan will work with your pump. Per your evidence of coverage (EOC), these Accu-Chek testing strips are non-covered and cannot be approved as reasonable and necessary. 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 pre-approve Accu-check blood glucose (sugar) test strips (CPT code A4253NU).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for Extracorporeal Shock Wave Therapy provided on August 31, 2021.  

You asked the Plan to pay for the Extracorporeal Shock Wave Therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is considered experimental.    

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 Extracorporeal Shock Wave Therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal an objective physical examination, objective knee imaging studies, or a diagnosis of the etiology of the member's knee pain to support the use of this treatment for this member's condition.  

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 Extracorporeal Shock Wave Therapy have not been met. Therefore, we decided that the Plan does not have to pay for Extracorporeal Shock Wave Therapy provided on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an LTACH.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care.  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 that in this case, the enrollee was admitted with acute on chronic respiratory failure due to chronic obstructive pulmonary disease. The record indicates that the enrollee is improving but still requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.   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 admission to an LTACH.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 12, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received at a lower level of care.  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 you were admitted with abdominal pain and bowel obstruction in setting of bladder cancer. The record indicates that you are improving. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.     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 admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a medical eye exam new patient (92004), and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), provided on October 15, 2021.  You asked the Plan to waive the copayment for medical vision services. 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 $30 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care.   You have been asked to pay a $30 copayment for the ophthalmologist vision care. This service falls within the  benefit vision care 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 medical eye exam new patient (92004), and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), provided on October 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiological supervision and interpretation of unilateral extremity angiography rendered on July 6, 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 are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 75710 (radiological supervision and interpretation of unilateral extremity angiography) and 37228 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37228. Code 75710 was not billed with an appropriate modifier to allow for separate payment. The 59 modifier is not supported as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the radiological supervision and interpretation of unilateral extremity angiography rendered on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cosmetic contact lenses fitting provided on October 4, 2021.  You asked the Plan to pay for the cosmetic contact lenses. 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 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 provides a $175 allowance for you to use toward the purchase price of eyewear from a network optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction. You may use the allowance once during a two-calendar-year period. The allowance can be used for the following items: eyeglass lenses, eyeglass frames, and/or contact lenses (excluding fitting or dispensing).  We looked at the file and the Plan's rules. Contact lenses fitting is not a covered service. Based on this information, we decided that the Plan's rules for coverage of the cosmetic contact lenses fitting have not been met. Therefore, we decided that the Plan does not have to pay for the cosmetic contact lenses fitting provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care office visit provided on October 1, 2021.  You asked the Plan to waive the copayment for an urgent care office visit. You say that you only went to urgent care to get a coronavirus (COVID-19) test done and there was no office visit. The Plan denied your request. The Plan says the provider billed for an office visit and there was no copayment for the COVID-19 test. The proper copayment was applied for the service.  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 $50 copayment for Medicare-covered urgently needed care when services are provided at an Urgent Care Center.   You have been asked to pay a $50 copayment for an urgent care office visit. An urgent care office visit falls within the Urgently needed 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 an urgent care office visit provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that you are very weak and have been losing weight. You need hospital care and rehabilitation services to rebuild your strength and find out why you are feeling ill. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can be met in an alternate 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 pay for 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable on outpatient medications with no issues requiring physician evaluation at least three times per week. You do require physical and occupational therapies but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program provided in an IRF. Your care needs can be met in a less intensive setting such as a skilled nursing facility.  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 pay for 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 hereditary genetic cardiac testing services provided on June 22, 2021. You asked the Plan to pay for the services provided. You say that the documentation substantiates the claim. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk screening genomic panels for suspected or documented cardiovascular disease.  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.  We looked at the file and the rules. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary genetic cardiac testing services provided on June 22, 2021.