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

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on September 14, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but, based on the medical records provided, you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your reported level of weakness and reduced endurance.  

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 IRF admission and services.
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 this is medically necessary. The Plan denied your request. The Plan says the care could be received in another 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. 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.  You were admitted for right total knee replacement and left total knee revision. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the emergency ambulance services (A0427 and A0425) provided on March 3, 2021.  You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the member's primary insurer paid more than the Medicare allowed amount so no additional payment will be made.  The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment amounts are determined by a formula and are the lowest of the excess of the actual charge minus the primary payment, the amount Medicare would pay if the services were not covered by a primary payer or the higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance services have been met. Specifically, the Plan, as a secondary payer is responsible for payment of the excess of the actual charge minus the primary payment as this amount is less than the Medicare allowed amount. Therefore, we decided that the Plan has to pay for the emergency ambulance services (A0427 and A0425) provided on March 3, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 7, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the expenses should be covered due to the enrollee's coronavirus diagnosis. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for services obtained from a specialist.   You have been asked to pay a $35 copayment for the specialist office visit. Please note that there are no cost-share waivers for coronavirus expenses as of January 1, 2021. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the detailed and extensive treatment planning (D9450), provided on July 13, 2021.  You asked the Plan to pay for the detailed and extensive treatment planning. You say that the plan should cover 50% of this service. The Plan denied your request. The Plan says this is not a covered service.  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. Specifically, this service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the detailed and extensive treatment planning (D9450), provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for complex cystometrogram with voiding pressure studies, intra-abdominal (51728, 51797), electromyography studies (EMG) of anal or urethral sphincter, other than needle (51784), and complex uroflowmetry (51741) provided on April 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for complex cystometrogram with voiding pressure studies, intra-abdominal, electromyography studies (EMG) of anal or urethral sphincter, other than needle, and complex uroflowmetry. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the member had a policy with no out-of-network (OON) benefits, was not referred by a participating provider, services rendered are available within the member's network and prior authorization had been denied.  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 complex cystometrogram with voiding pressure studies, intra-abdominal (51728, 51797), electromyography studies (EMG) of anal or urethral sphincter, other than needle (51784), and complex uroflowmetry (51741) provided on April 26, 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 Neulasta 6mg/0.6ml for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the plan's preferred colony stimulating factors have been tried and failed.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation of a trial and failure of the plan's preferred drugs, and there is no documentation that these drugs would likely be less effective and/or likely to have adverse effects for the enrollee.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta 6mg/0.6ml for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve occupational therapy (OT) services (97535, 98960, 97166) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OT services. You say that these services are medically necessary. The Plan denied your request. The Plan says the provider in this case is out-of-network. Out-of-network services are only covered in certain limited circumstances. The requested care is not urgent or emergent and can be received from in-network providers.  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 occupational therapy (OT) services (97535, 98960, 97166) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 19, 2021 to June 8, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the initial RAP claim was not submitted within 5 calendar days from the start of care.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that this episode of care began on May 19, 2021. The record also indicates that the RAP was not submitted until August 27, 2021. This is outside of Medicare's allowable timeframe.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 19, 2021 to June 8, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pre-approve the epidural steroid injection. We decided that the Plan does not have to pre-approve the facet joint injection.   You asked the Plan to pre-approve the combination of injections. You say that this is medically necessary. The Plan says that there is no documentation of an absence of radicular pain.  We decided that the Plan has to pre-approve the epidural steroid injection.   The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for the epidural injection and the facet joint injection. Our reviewer says that performing both an epidural and facet blocks on the same day does not meet the criteria set out in the Medicare guidelines. Our physician reviewer found that, however, the epidural steroid injection itself is medically reasonable and necessary for an enrollee with chronic low back pain, with spinal stenosis, neurogenic claudication, and radiculopathy.  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 epidural steroid injection have been met. Therefore, we decided that the Plan has to pre-approve the epidural steroid injection.      We also decided that the Plan does not have to pre-approve the facet joint injection.  The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for the injections. Our reviewer says that while the epidural injection is considered medically reasonable and necessary, our physician reviewer found that in the presence of radiculopathy, the facet joint injection is not medically reasonable or necessary. Facet joint injections are not supported in the presence of other probable pain generators.  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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint injection.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve cataract surgery. You say that you trust this doctor and it is hard for you to trust any other 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 you can be treated 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 cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of thoracic spine provided.  You asked the Plan to pre-approve CT scan services. You say that this is medically necessary for the enrollee's condition. 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 CT scans are covered only when they are 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 CT scan services. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee had a follow up magnetic resonance imaging (MRI) scan of the thoracic spine in January 2022 that showed no change in the appearance of the previously seen lesion on another MRI. The lesion has not been seen on CT scan in the past. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of thoracic spine provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the stent placement services provided on July 16, 2021.  You asked the Plan to pay for the services provided. You say that documentation supports separate payments. The Plan denied your request. The Plan says no separate payment is made per Medicare.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 92929 is percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure).  We find that CPT code 92929 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the stent placement services provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the vision frames (V2020), provided on March 2, 2021.  You asked the Plan to pay for the vision frames. You say that the service should be covered. The Plan denied your request. The Plan says that this service is not covered when provided out-of-network.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for coverage of the vision frames have been met. Specifically, the Plan's EOC does not indicate that you cannot use out-of-network providers for supplemental benefits. Therefore, we decided that the Plan has to pay for the vision frames (V2020), provided on March 2, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210), panoramic radiographic image (x-ray) (D0330), and limited oral evaluation (D0140), provided on August 5, 2021.  You asked the Plan to pay for the surgical removal of erupted tooth, panoramic x-ray, and limited oral evaluation. You say that the services should be covered. The Plan denied your request. The Plan says you received these services from a non-participating provider.  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 the surgical removal of erupted tooth (D7210), panoramic radiographic image (x-ray) (D0330), and limited oral evaluation (D0140), provided on August 5, 2021.