Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 17, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 17, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (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 is receiving appropriate care at the present acute care hospital. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive eye examination, medical examination and evaluation with initiation of diagnostic and treatment program (92004) to be provided by a tertiary level, out of network (OON) provider.
You asked the Plan to pre-approve the eye exam. You say that this provider is one of the country's leading eye surgeons who specializes in corneal transplants. You are going blind and this surgery is the one opportunity you have to maintain what vision you are left. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan agrees a tertiary level corneal specialist is appropriate and has approved the initial evaluation with an in network tertiary level 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 comprehensive eye examination, medical examination and evaluation with initiation of diagnostic and treatment program (92004) to be provided by a tertiary level, out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided from
January 15, 2020, through July 17, 2020.
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request.
The Plan says the enrollee is responsible for the copayment that applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay $35 copayment for vision care, Medicare-covered eye exams.
The enrollee has been asked to pay $35 copayment for the ophthalmological services. The ophthalmological
services falls within the vision care, Medicare-covered eye exams benefit category. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for ophthalmological services provided from
January 15, 2020, through July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #18 and 31 and core buildups, including any pins when required (D2950) for tooth #18 and 31.
You asked the Plan to pre-approve the crowns and core buildups. You say that the conservative restoration failed, and the enrollee needs a permanent crown. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #18 and 31 and core buildups, including any pins when required (D2950) for tooth #18 and 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0270) or pay more for the resin-based 
composite (D2394) provided on August 23, 2021.

You asked the Plan to pay for the bitewing x-ray and to pay more for the resin-based composite. You say that 
you feel that you should not be charged for these services. The Plan denied your request. The Plan says your 
benefits for bitewing x-rays have been satisfied and the frequency limitation has been exceeded. The Plan also 
says that the resin-based composite was covered at 50% according to your plan 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, bitewing x-rays are limited to one set 
per calendar year. The record shows that you received a bitewing x-ray (D0270) on March 22, 2021 and your 
bitewing x-rays benefit had been exhausted. You are also responsible for a 50% coinsurance for the resin-based 
composite.

Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) or pay more for the 
resin-based composite (D2394) provided on August 23, 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 the enrollee will benefit from the highest level of
rehabilitation to regain her maximum function. The Plan denied your request. The Plan says that the enrollee
can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cardiac arrest. An
automatic implanted defibrillator was placed. The enrollee's medical conditions are stable. There are no
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on
June 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because
the services provided were medically necessary and meet all applicable professionally recognized standards of
healthcare. The Plan denied your request. The Plan says enrollee's must receive their medical services from an
in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90832)
provided on June 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services and
outpatient therapy services provided from June 16, 2020 to June 18, 2020.
You asked the Plan to waive the cost share for the outpatient services. You say that you feel the enrollee should
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says the enrollee received outpatient surgery and outpatient rehab services on the
dates of service at issue in this appeal. The Plan says that the correct cost share has applied per the enrollee's
contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a 20% coinsurance for each surgical or observation room service you get at an outpatient hospital and
a $40 copayment for Outpatient rehab services.
We looked at the file, the Plan's contract and Medicare rules. The file shows the enrollee received outpatient
surgery in an outpatient hospital setting provided from June 16, 2020 to June 18, 2020. The enrollee has been
asked to pay a 20% coinsurance for the outpatient surgery, totaling $2211.49. The outpatient surgery falls
within the Outpatient hospital services benefit category. The file also shows the enrollee received outpatient
rehab services from June 16, 2020 to June 18, 2020. The enrollee has been asked to pay a $40 copayment for
each outpatient rehab visit, totaling $80. The outpatient rehab services fall within the Outpatient rehabilitation
services benefit category. The enrollee's total cost share for the June 16, 2020 to June 18, 2020 dates of service
is $2291.49. This means that the enrollee has been asked to pay the correct amount based on the contract with
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the cost share for the outpatient surgery services
and outpatient therapy services provided from June 16, 2020 to June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an endosteal implant (D6010) provided by a participating 
provider on July 26, 2021.

You asked the Plan to pay for an endosteal implant. You say that you purchased extra dental coverage in case 
you needed dental work. You say that this denial is a surprise. The Plan denied your request. The Plan says the 
rendered dental service is not a covered 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 an 
endosteal implant (D6010) provided by a participating provider July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2394) provided on July 30,
2021.
You asked the Plan to pay for the resin-based composite. You say that the enrollee did not have dental
treatments until age four and her dental health was stunted. You also say that the enrollee's previous primary
insurance knew this and did not deny payment. The Plan denied your request. The Plan says benefits for this
service have been satisfied and the frequency limitation has been exceeded.
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, restorations (fillings) are limited to two
procedure codes per calendar year. The record shows that the enrollee received two resin-based composites on
June 8, 2021 which were covered by the Plan and the enrollee's restorations benefit had been exhausted.
Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2394) provided on
July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4557) provided on September 18, 2021.

You asked the Plan to pay for the lead wires. You say that you would like reconsideration because CPT code 
A4557 is not included in another supply. The Plan denied your request. The Plan says since a TENS unit has 
been purchased in the previous 12 months, it would not be appropriate to bill for lead wires separately within 
the 12 months after purchase.

The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lead wires have not been met. Specifically, the record indicates that the member purchased a 
TENS unit with lead wires on August 18, 2021. The lead wires at issue were provided within the 12 months 
after purchase. The documentation does not show any evidence that these lead wires were medically reasonable 
and necessary. Therefore, we decided that the Plan does not have to pay for the lead wires (A4557) provided on 
September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment to extraspinal regions 
(98943) provided September 20, 2021 to September 22, 2021.

You asked the Plan to pay for the chiropractic services. You say that you were not made aware of any kind of 
difference in care or in billing. You were not aware the services would not be covered. The Plan denied your 
request. The Plan says this service is 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 chiropractic manipulative treatment to extraspinal regions (98943) 
provided September 20, 2021 to September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental appliance for sleep apnea.
You asked the Plan to pre-approve the dental appliance. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan follows Medicare rules. Medicare rules say that the beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test, the beneficiary has a Medicare-covered sleep test that meets one of the criteria, and the device is ordered by the treating practitioner following a review of the report of the sleep test. 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 dental appliance. Our reviewer says that the dental appliance for sleep apnea does not meet the criteria for coverage. Our physician reviewer found the documentation provided does not contain a recent sleep study and a recent in person evaluation and order for the device/appliance. 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 dental appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental appliance for sleep apnea.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure does 
not meet criteria.

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 Vertiflex Superion device placement 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex device is experimental, and more research is 
needed to show its safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on January 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the automatic external defibrillator. You say that you are appealing this decision. 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 an automatic external defibrillator provided on January 6, 2021, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented need for 30 degree head up or for pain relief that a regular bed cannot do.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation does not support that you have a condition that requires frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in a way that an ordinary bed is not able to. 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.