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

 We decided that the Plan does not have to pay for an x-ray provided on June 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the x-ray. You say that the enrollee requires the use of mobile imaging due to limited mobility. The Plan denied your request. The Plan says no prior authorization was obtained.  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. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the x-ray provided on June 20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an X-Ray examination to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve X-Ray. You say that it is an inconvenience for the enrollee to have this X-Ray at an in-network provider. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this test can be performed by an in-network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an X-Ray examination to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultraviolet light therapy provided on September 11, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the ultraviolet light therapy. You say that the authorization was cancelled.  The Plan denied your request. The Plan says no prior authorization was obtained.  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. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for ultraviolet light therapy provided on September 11, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Zip Fusion device.  You asked the Plan to pre-approve a Zip Fusion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Zip Fusion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Zip Fusion device is experimental. More research is needed to show safety and efficacy of the device.  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 Zip Fusion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Zip Fusion device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron 8 mg tablet.  You asked the Plan to pre-approve Ondansetron. You say that the criteria for coverage for this antiemetic are satisfied. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Specifically, the criteria for oral anti-emetics drugs specifies that the requested drug must be being used as a full therapeutic replacement for an intravenous antiemetic drug.    In this case, this is not the case. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 8 mg tablet.   Benefits for Ondansetron 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the procedure.          We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on December 15, 2020.  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 not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 15, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve kidney imaging morphology with vascular flow and function.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that current evidence does not support procedure in this clinical scenario.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 requested services. Our physician reviewer found that the enrollee has obstructive uropathy and recurrent stones. She has been referred for possible reconstruction of urinary tract. She has complex urinary tract anatomy and needs non-invasive guidance to evaluate for surgical procedure. The information gathered from this study will directly impact decisions regarding surgical options. The requested study is indicated as it will be integral to decisions made regarding a potential surgical procedure. Therefore, the requested service is medically reasonable and necessary 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve kidney imaging morphology with vascular flow and function.

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 foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that orthotics is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 13, 2020.  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 not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.        We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided on December 23, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON lab services. You say that these services were medically necessary for the patient's condition and your lab is the only one that performs this test. The Plan denied your request. The Plan says neither the lab that provided these services nor the ordering provider are network providers with the Plan.  The Plan says that unauthorized, non-plan care is not covered.  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. The fact that your lab may be the sole provider of these services does not negate the provider's obligation to secure authorization from the Plan or a network provider prior to rendering services. 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 lab services provided on December 23, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the $25 copayment for specialist office services provided on May 6, 2021  You asked the Plan to waive this copayment. You say that office staff does not qualify as a specialist. 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 $25 copayment for specialist office services.  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 $25 copayment for a specialist office visit (99203) provided on May 6, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oral enteral nutritional supplements.  You asked the Plan to pre-approve nutritional supplements. You say that you are unable to chew due to your condition and it is imperative that you get this nutrition. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because orally administered enteral nutrition products are not covered.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve oral enteral nutritional supplements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a dental consultation and extractions to be provided by an oral surgeon.  You asked the Plan to pre-approve dental services. You say that you are in pain due to your condition and were referred to this provider. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because services performed by an oral surgeon are not covered by the Plan's dental benefits.    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 when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a dental consultation and extractions to be provided by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after December 1, 2021.

You asked the Plan to pre-approve SNF care. You say that you are having stitches removed and are still under care at the facility. The Plan denied your request. The Plan says the denial of authorization for continued skilled nursing facility (SNF) care after December 1, 2021 is correct.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after December 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health care.  You asked the Plan to pre-approve home health care. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 care. Our reviewer says that Medicare criteria are not met. Our physician reviewer found based on the documentation provided, the enrollee is attending outside appointments, calling into question her homebound status. As such, the requested, ongoing home health care services are not medically necessary or reasonable.  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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gradient compression sleeves (A6549).  You asked the Plan to pre-approve gradient compression sleeves. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that certain wound care items are not covered under the surgical dressing benefit.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gradient compression sleeves have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression sleeves (A6549).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 23, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 this service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, the enrollee does not meet the criteria for this testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 30-days of physiological monitoring services provided on September 17, 2020 billed with codes 99453 and 99454.  You asked the Plan to pay for the 30-days of physiological monitoring services. You say that this claim was underpaid. The Plan denied your request. The Plan says it was decided to make payment for the services described by 99454 on September 1, 2020. However, the other date of service is 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 99453 is Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. The definition of code 99454 is Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.  We find the records do not support the billing of 99453 and 99454 on September 17, 2020. Only 16 days of monitoring were between the two codes. Since no more than 30 days of monitoring are in evidence, only the September 1, 2020 is supported. Based on this information, we decided that Medicare rules for coverage of the 30-days of physiological monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the 30-days of physiological monitoring services provided on September 17, 2020 billed with codes 99453 and 99454.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 26, 2021, to March 19, 2021.  You asked the Plan to pay for the SNF services. You say that these claims were submitted with the correct TOBs from the 21X range. The Plan denied your request. The Plan says the claim was received with a TOB reported as 121 which is not valid for a SNF claim.    The Plan must follow Medicare rules. Medicare rules say that TOB 21X is required for SNF claims.  Although you state that the correct TOB was reported for these claims, the claim as it was received by the Plan shows a TOB of 121 which is not valid for this service. A corrected claim may be necessary for this situation. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 26, 2021, to March 19, 2021.