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

 We decided that the Plan does not have to waive the copayment for a CT scan of the pelvis (72194) provided on April 12, 2021.  You asked the Plan to waive the copayment for the CT scan of the pelvis. You say that the services should be covered as they are too expensive. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $225 copayment for Outpatient diagnostic tests and therapeutic services and supplies.         You have been asked to pay a $184.11 copayment for a CT scan of the pelvis, which is less than the $225 stated in the Plan's contract. the CT scan of the pelvis 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 copayment for a CT scan of the pelvis (72194) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.  You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says the services are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. In this case, the medical records provided do not show that the results of testing will impact the clinical management of the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 16 additional physical therapy visits.  You asked the Plan to pre-approve the 16 additional visits. You say that you would like reconsideration because the requested physical therapy is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested physical therapy visits.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 16 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have been instructed in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  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 16 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy visits.
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 May 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.  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 mental health services provided on May 21, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
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 the stay is not medically necessary based on LTACH criteria. The Plan states the enrollee's needs can safely be met in their current hospital setting and once the enrollee's doctor decides they are medically stable, the enrollee can safely receive the services they need in an alternate 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 the enrollee appears to be improving, but still requires additional short-term acute care hospital services that can safely be 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 the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.  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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867, 90868, 90869).  You asked the Plan to pre-approve the services. You say that you have had TMS before and it has helped with your condition significantly, and you do not understand if this was covered by the Plan before and why it was not covered this time. The Plan denied your request. The Plan says you need to show that other treatments for major depressive disorder, single episode, severe (without psychotic features) have not worked.  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 services. Our physician reviewer found you do not meet the clinical criteria for the use of Repetitive Transcranial Magnetic Stimulation (rTMS) therapy utilizing LCD (L33398) as you do not show improvement of fifty (50) percent as your PHQ 9 went from 13 to 9 according to documentation. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867, 90868, 90869).
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 the stay is not medically necessary.  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, but still requires additional short-term acute care hospital services that can safely be 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 patient requires that are not already available and covered at the current facility. Transfer to the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on July 23, 2021.  You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as you cancelled this appointment and did not go. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $15 copayment for Physician/Practitioner services, including doctor's office visits.    You have been asked to pay a $15 copayment for the office visit. There are medical records provided confirming that you did receive services on July 23, 2021. 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 office visit (99214) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve hearing aids to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says you must get your care from network providers. Usually, the Plan will not cover care from a provider who does not work with the health Plan. But sometimes this rule does not apply, for example, the plan covers emergency or urgently needed care from an out-of-network provider. If you need care that our Plan covers, and our network providers cannot give it to you, then you can get the care from an out-of-network provider. You must obtain a prior authorization from your PCP/Care Team or the Plan before you seek care from an out-of-network provider.   Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has provide 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 item at issue in this appeal. We found no exception that would require the Plan pre-approve the hearing aids. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97110) provided on June 30, 2021.  You asked the Plan to waive the copayment for the physical therapy services. You say that the services should be covered at an in-network rate as the provider you saw is in-network. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $55 copayment for Outpatient rehabilitation services.     You have been asked to pay a $55 copayment for physical therapy services. The record indicates that the provider seen is out-of-network. Physical therapy services fall within the Outpatient rehabilitation 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 physical therapy services (97110) provided on June 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colonoscopy services provided on August 2, 2021.  You asked the Plan to pay for the services provided. You say that the diagnosis codes billed are correct. The Plan denied your request. The Plan says the claim processed correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The colonoscopy codes at issue have a multiple procedure indicator of 3.  Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay for the colonoscopy services provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1831).  You asked the Plan to pre-approve the orthosis. You say that you would like to make an appeal for the knee brace that got denied. The Plan denied your request. The Plan says the requested knee brace 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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee's physician prescribed a regular knee support without hinges. There was insufficient support made for an orthotic that includes hinges as they have not failed regular orthotics. Therefore, this request for myoelectric knee orthosis will be considered not medically necessary at this time and based on the provided documentation.  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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1831).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is currently at an inpatient rehabilitation facility (IRF) with multiple wounds. He received oral and inhaled medications and has stable vital signs. He received physical and occupational therapy and needs supervision/touch assist for functional mobility, including gait. He needs varied assist for activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the dental services provided from September 21, 2020, through November 2, 2020.  You asked the Plan to pay for the dental services. You say that you would like these services reprocessed and approved for payment. The Plan denied your request. The Plan says that the services have processed correctly.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, there are multiple explanation of benefits that seem to indicate that the services have been processed. However, it is unclear what services were overturned. We requested an updated explanation of benefits to clarify discrepancies in the case file and this was not returned to us. The plan has not submitted sufficient information to determine what services were denied and why. Therefore, we decided that the Plan has to pay for the dental services provided from September 21, 2020, through November 2, 2020.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 5, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported.  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, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."  We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on January 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the podiatry services provided on August 27, 2021.  You asked the Plan to pay for the services provided. You say that you needed treatment to resolve your pain. The Plan denied your request. The Plan says that routine foot care is not a covered benefit.  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 services at issue were provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the podiatry services provided on August 27, 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.