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

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
You asked the Plan to pre-approve 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter (K0800).  You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 power scooter. Our reviewer says that the power scooter is not medically necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the patient's mobility deficit for mobility within his home cannot be helped by the use of a walker or manual wheelchair.  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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF).
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be met at a lower level of care.
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 pay for the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the admission evaluation and management (EM) services provided on June 10, 2021, billed with code 99223-AI.  You asked the Plan to pay for the EM services. You say that the records should be reviewed as both providers should be paid for this visit. The Plan denied your request. The Plan says the records show that the billing provider performed a single admission EM service. This service was reimbursed to this physician on July 22, 2020. This claim is a duplicate of the paid claim.  The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims are automatically denied; however, these can be appealed with evidence to support the claim is not duplicate.  In this case, neither the billing of the second claim nor the records support that two visits occurred on this date of service. Since this provider was reimbursed for these services on a prior claim, we find that denial as duplicate was appropriate. Therefore, we decided that the Plan does not have to pay for the admission evaluation and management (EM) services provided on June 10, 2021, billed with code 99223-AI.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve coronary CT angiography (CTA).  You asked the Plan to pre-approve a CTA. 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 follows Medicare rules. Medicare rules say that a CTA is only covered for certain indications.  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 a CTA. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has dyspnea on exertion and chest pain. A radionuclide stress test was positive for ischemia, and the next step would be coronary arteriography, with no clear benefit from CTA at this time. Clinical guidelines for the use of coronary CTA have not been met based on review of the submitted clinical documentation. As a result, at this time coronary CTA would not be considered medically reasonable and necessary in this enrollee's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve coronary CT angiography (CTA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you want this service covered. The Plan denied your request. The Plan says the enrollee was referred by a non-participating physician to the non-participating provider for service. They also determined that the services were not urgent or emergent.
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 an office visit provided on March 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Pharmacogenomics Testing (81227, 81355, 81225, 81226).  You asked the Plan to pre-approve the Pharmacogenomics Testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that that pharmacogenomics tests are indicated when medications are being considered for use (or already being administered) that are medically necessary, appropriate, and approved for use in the patient's condition and are known to have a gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by the FDA or Clinical Pharmacokinetic Implementation Consortium guidelines.  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 Pharmacogenomics Testing. Our reviewer says that the requested testing is not medically necessary. Our physician reviewer found the records do not document that the enrollee's provider has a specific plan for a medication change, which specific medications may need gene testing nor that this gene testing was being ordered and will be used by the provider for medical management of the enrollee'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 Pharmacogenomics Testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Pharmacogenomics Testing (81227, 81355, 81225, 81226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a robotic upper extremity orthosis (L8702).  You asked the Plan to pre-approve the robotic upper extremity orthosis. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is 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 the robotic upper extremity orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the MyoPro 2 Motion-G device at issue in this case meets Medicare criteria for coverage. Current clinical guidelines designate robotic therapy to uncertain utility, with unproven benefit in the home environment.  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 robotic upper extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a robotic upper extremity orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of February 9, 2022.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care as of February 9, 2022 is correct.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of February 9, 2022. Our physician reviewer found it is not expected that the enrollee will improve in a reasonable period of time beyond the date in question, as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment without showing any acute threats to safety. It is not medically reasonable and necessary to have continued psychiatric care provided at the inpatient level of care rather than a lower level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on January 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that the enrollee had the incorrect insurance at the time. The Plan denied your request. The Plan says there was no indication any attempt was made to obtain prior authorization for the out-of-network 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 5, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 enrollee is not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided by an
out-of-network provider on August 10, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you are appealing this
claim. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing
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 $40
copayment for provider and professional services at an out-of-network primary care physician's office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided by an out-of-network provider on
August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on October 19, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you cannot afford to pay the provider. The Plan denied your request. The Plan says these services
exceed the maximums allowed per period.
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 evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on October 30, 2018 and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory work provided by an in-
network provider from September 15, 2021, to October 8, 2021.
You asked the Plan to waive the copayments for the laboratory work. You say that you have to have laboratory
work done every week as a part of your cancer treatment. You say you cannot afford this copayment every
week. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing
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 $20
copayment for laboratory services at an in-network freestanding laboratory.
You have been asked to pay a $17.49 copayment for the laboratory work on September 15, 2021, which is less
than the standard copayment amount. You have also been asked to pay a $20 copayment for the laboratory
work on October 8, 2021. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic
services and supplies" 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 copayments for laboratory work provided by an in-network provider from
September 15, 2021, to October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on January 15, 2021.
You asked the Plan to pay for a computed tomography scan. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.
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 a computed tomography scan (70450) provided on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 29, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from January 29, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from January 29, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 29, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond January 29, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from January 29, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 29, 2022, forward.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on September
2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no
documentation of contact in the patient record.
The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's
physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the
physician are not successful, the CP must notify the physician within a reasonable time that he or she is
furnishing services to the patient. Additionally, the CP must document, in the patient's medical record, the date
the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did
not succeed, that date and manner of notification to the physician.
We looked at the file and Medicare rules. The records in this case do not show that the CP made an attempt to
consult with the enrollee's physician within a reasonable time after the services were provided. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pay for the outpatient mental health services provided on September 2,
2021.