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

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular RFA. You say that this procedure allows flexibility to achieve optimal neurolysis supporting clinical outcomes. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because genicular RFA is experimental/investigational.
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 genicular RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure that is the subject of ongoing clinical trials.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 24, 2021 and billed under codes 81407, 81408, and 81479.
You asked the Plan to pay for genetic testing provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, codes 81407, 81408, and 81479, were denied as statutorily excluded.
The Plan follows Medicare rules. The rules explicitly say that cardiovascular screening tests are not covered. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 24, 2021 and billed under codes 81407, 81408, and 81479
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for office visits you had with an out-of-network provider from January 26, 2021, to March 30, 2021.
You asked the Plan to waive the coinsurance for the out-of-network physician services. You say that the only reason you joined this plan is because your doctor was in-network. You don't understand how the doctor is now considered out-of-network. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network physician services.
You have been asked to pay 50% coinsurance for the out-of-network physician services. We confirmed on the Plan's online provider directory that this provider is not a network provider with your specific plan. 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 coinsurance for office visits you had with an out-of-network provider from January 26, 2021, to March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on October 31, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you would like the Plan to consider this bill. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for advanced imaging services in a doctor's office. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the advanced imaging services in a doctor's office 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 computed tomography (CT) scan of the chest you had on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three resin-based fillings (D2330, D2331) provided on June 9, 2021.
You asked the Plan to pay for the fillings. You say that you thought you were covered for these services. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for three resin-based fillings (D2330, D2331) provided on June 9, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health counseling services provided on March 1, 2021, to March 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON behavioral health counseling services. You say that neither you nor the provider knew that these services were out-of-network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. In addition, this provider is not a Medicare-qualified mental health care professional.
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 did not pre-approve the item/service at issue. In addition, this provider is not a Medicare-qualified mental health care provider. 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 behavioral health counseling services provided on March 1, 2021, to March 12, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.
You asked the Plan to pre-approve home health skilled nursing care. You say that home health services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for home health care have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health skilled nursing care. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that continued skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing care have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on May 24, 2021, and the inpatient hospital services you received from May 28, 2021, to June 1, 2021.
You asked the Plan to waive the copayments for the ER visit and the inpatient hospital services. You say that you believe these copayments should be waived. You stated that you were coerced into going to the ER. You also stated that you were discriminated against during your hospitalization. The Plan denied your request. The Plan says you were charged these copayments 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 $90 copayment for emergency room visits and a $175 copayment per day for days 105 for inpatient hospital services.
You have been asked to pay a $90 copayment for the ER visit. For the inpatient hospital services, records show that you were in the facility for 4 days. You were charged a $175 copayment per day, for a total of $700 for the inpatient services. This means that you have been asked to pay the correct amounts based on your contract with the Plan. These cost sharing amounts apply regardless of the reason for the services or your satisfaction with the services. 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 the emergency room (ER) visit you had on May 24, 2021, and the inpatient hospital services you received from May 28, 2021, to June 1, 2021.
Your complaint about being coerced to go to the ER is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on April 23, 2021.
You asked the Plan to pay for the testing services. You say that this is the only lab that uses diagnostic tools that are selected for the test. The Plan denied your request. The Plan says the testing does not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under certain medical indications. We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the testing was ordered to determine a specific diagnosis or treatment strategy, or that the results of testing will impact clinical management to improve the enrollee's outcome. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on April 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95957, 95909, and 95886 provided on September 21, 2020.
You asked the Plan to pay for the medical services. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the billed codes are:
95957 - Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) 95909 - Nerve conduction studies; 5-6 studies 95886 - Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) We asked our coder 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 medical services. Our reviewer says that the services as billed are not supported in the medical documentation. Our reviewer found the technical report documents Train of Four was performed and reported with CPT 95957. This is an inappropriate code to report for this service. Train of Four is inclusive to the primary intraoperative neuromonitoring procedure, and therefore not separately reported. In addition, for CPT 95909, the technical report does not document Nerve Conduction studies, as the report describes "pedicle screw stimulation". Nerve Conduction studies include measurements of amplitude, latency, and conduction velocity. This was not documented in the Technical report. Finally, CPT 95886 would not be covered, as the required criteria has not been performed. Nerve Conduction studies were not performed which is included in CPT 95886. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95957, 95909, and 95886 provided on September 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic services coded as 97110 provided on March 12, 2021.
You asked the Plan to pay for the therapeutic services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services as they have been billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We asked our coder 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 therapeutic services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found CPT 97110 is an inappropriate code to report for therapy services performed in the home. Therapy visit documents enrollee is home bound, and services were performed in the home. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for documented services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic services coded as 97110 provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 26, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you do not have benefits with out-of-network doctors.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has 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 did not pre-approve the eye refraction. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. 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 an eye refraction provided on July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the documentation provided supports the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met at an alternate 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy and occupational therapy. By the dates in question, the enrollee was at a standby assist to supervision level with functional mobility, including gait to 350 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.
You asked the Plan to pre-approve the Freestyle Libre 14-day sensor kit. You say that the enrollee is reliant on 2 insulin injections daily and has required frequent dose adjustments because of uncontrolled diabetes. You say that the requested item will help the enrollee to better and more safely manage her insulin dependent diabetes. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 the Freestyle Libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.
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 you will not be able to take care of yourself without rehabilitation. 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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health physical therapy services.
You asked the Plan to pre-approve home health services. You say that you will benefit from the services. The Plan denied your request. The Plan says no skilled needs were identified.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health services. Our physician reviewer found that the records do not show skilled nursing or therapy services are required to effectively provide treatment to improve your condition, or to perform a maintenance program to maintain your condition or prevent deterioration. You have had prior physical therapy. The most recent evaluation notes that you are not a good candidate for ongoing home health therapy. Therefore, home health services are not reasonable and necessary for the treatment of your condition by a skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health physical therapy services.