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

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON office visits. You say that you are in extreme pain and the requested services are medically necessary. The Plan denied your request. The Plan says there are in network providers within a reasonable distance from your location, that can provide the office visits needed.
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 out of network services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
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 do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided from March 24, 2021 to April 19, 2021.

You asked the Plan to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, this code has a status code of "B". A status code of B means that this code is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided from March 24, 2021 to April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion.

You asked the Plan to pre-approve the insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion.. 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 the insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion are 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 the insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion.. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee underwent cataract surgery and trabeculopplasty. The provided records do not indicate that the enrollee was being treated with an ocular hypotensive medication. Therefore, the enrollee does not meet criteria for the requested services. 

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 insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion. have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork and additional device insertion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4) and six crowns (D2791 x6).
You asked the Plan to pre-approve the scalings and planings and crowns. You say that you were told if you joined this plan you were told that root canals and all dental treatment would be covered. The Plan denied your request. The Plan says these procedures are not listed as covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4) and six crowns (D2791 x6).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Affinity, per square centimeter (Q4159) provided to the enrollee on March 31, 2021.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that this is not covered.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The documentation is insufficient to demonstrate that the Affinity allografts were medically reasonable and necessary for the enrollee in this case. The case file does not contain documentation of failure of standard wound care measures. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
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 pay for the Affinity, per square centimeter (Q4159) provided to the enrollee on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can be met in the skilled nursing facility setting.

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. The enrollee does not require the intensity of services provided at an IRF. Specifically, 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria
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 has not required mechanical ventilation. There are no services available
at the LTACH that the enrollee requires that are not available at the health care setting being offered by the
health plan.
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 the telephone evaluation and management service (99442) provided on April 14, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $10 for each covered telehealth visit or consultation in an outpatient location with your primary care physician (PCP) or other primary care provider.
You have been asked to pay a $10 copayment for the telephone evaluation and management service provided by a primary care provider. 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 telephone evaluation and management service (99442) provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol.

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 self-administered drugs are not covered.

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. Therefore, we decided that the Plan does not have to pre-approve Tramadol.

Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray services received by a chiropractor on April 5, 2021.

You asked the Plan to pay for the office visit and x-ray services. You say that without the x-rays the provider would not have had a clear picture of what was causing your back pain. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and x-ray services received by a chiropractor on April 5, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis and which can only be provided on an inpatient basis in a SNF.
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 SNF care is medically reasonable and necessary. You have had some rectal bleeding and constipation and appear to require a bowel program and monitoring of rectal bleeding, complete blood count and therefore skilled nursing for observation is medically necessary. Your functional level has declined significantly and you are now following 75% of commands. You do require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF on a daily basis. Our physician reviewer found that your condition meets Medicare criteria for SNF services. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 a negative wound pressure therapy pump.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says the request is for over four months of treatment.
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 pump. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the guidelines state that a negative pressure wound therapy (NPWT) pump and supplies will be denied as not reasonable and necessary when four months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the most recent wound. 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 pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a negative wound pressure therapy pump.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on February 11, 2021.

You asked the Plan to pay for psychotherapy services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because there was no documented contact between the clinical psychologist and the primary care physician.

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. 

In this case, the provided medical records do not support the Plan's assertion of no contact between the clinical psychologist and the primary care physician. The Plan has not indicated whether the referring physician is an in-network provider. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on February 11, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion or specialty drug administration, per visit, up to 2 hours (99601) provided on January 3, 2021.
You asked the Plan to pay for the home infusion service. You say that the service was medically necessary. The Plan denied your request. The Plan says procedure code 99601 is assigned a status code "I", indicating that this code is not valid for Medicare purposes. The Plan also says that services with a status code of "I" are not payable.
The Plan must follow Medicare rules. Medicare rules say that a procedure code with status code "I" is not valid for Medicare purposes and is not payable by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion service have not been met. Specifically, the procedure code has a status code "I"
and is not payable by Medicare. Therefore, we decided that the Plan does not have to pay for home infusion or specialty drug administration, per visit, up to 2 hours (99601) provided on January 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the weight management services.
You asked the Plan to pay more for the weight management services. You say that the envelope was returned,
and you sent it back before the deadline. You say that the mail situation is not your fault and you should be
reimbursed. The Plan denied your request. The Plan says you were reimbursed the proper amount.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to an
annual maximum of $150 towards program fees for weight loss programs.
The Plan's rules for additional coverage of weight management services have not been met because the Plan
reimbursed the proper amount based on the proof of payment received. Therefore, we decided that the Plan
does not have to pay more for the weight management services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99221) provided on December 2, 2020.

You asked the Plan to pay for hospital care. You say that there are no conflicting billed codes for this service. The Plan denied your request. The Plan says this cannot be paid without a required modifier.

The Plan must follow Medicare rules. Medicare rules say that evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately. In addition to the evaluation and management code, modifier "-57" (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery. 

We looked at the file and Medicare rules. The records show that the service at issue resulted in the decision to
perform a laparoscopic cholecystectomy (47563), a major surgery, on December 3, 2020. While the service at issue is not included in the global surgical package, modifier "-57" is required to identify this visit which resulted in the initial decision to perform surgery. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99221) provided on December 2, 2020.