Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism correcting function of an intraocular lens (V2787) provided on April 7, 2021.

You asked the Plan to pay for this lens upgrade. You say that you received a laceration in the right cornea creating an ulcer which required you to have eight months of treatment. You also say the lens was toric and even with it, you had to use glasses. The Plan denied your request. The Plan says the Plan contract is clear that these lenses are not covered.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. 

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism correcting function of an intraocular lens (V2787) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection with a direct probe technique (87660) provided on April 23, 2021.

You asked the Plan to pay for infectious agent detection with a direct probe technique. You say that this is supported in the records. The Plan denied your request. The Plan says this code is not documented.

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 87660 is infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique. 

We find that CPT code 87660 is not supported in the medical record. Specifically, the submitted records do not document the use of a direct probe. Based on this information, we decided that Medicare rules for coverage of infectious agent detection with a direct probe technique have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection with a direct probe technique (87660) provided on April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided by an out-of-network provider on December 20, 2020.

You asked the Plan to pay for initial hospital care. You say that you are requesting reconsideration for these services. The Plan denied your request. The Plan says without medical records, they are unable to verify if these services were rendered.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Specifically, the documentation submitted does not include clinical information to verify if this service was rendered on the billed date of service. There is insufficient information to confirm that Medicare coverage criteria have been met. Of note, the record indicates that the Plan requested this information from the provider and did not receive a response. 

Therefore, we decided that the Plan does not have to pay for initial hospital care provided by an out-of-network provider on December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve robotic prostatectomy surgery to be provided by out-of-network providers.

You asked the Plan to pre-approve the out-of-network surgery. You say that your doctor told you that there are only two (2) hospital that can provide this service. The Plan denied your request. The Plan says there are in-network providers with the appropriate training and experience to provide the requested service. 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 robotic prostatectomy surgery to be provided by out-of-network providers.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 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 the patient was admitted for dehydration, metabolic acidosis, urinary tract infection and acute kidney injury. Medical problems are stable. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has a very complicated medical history with multiple medical issues and long hospitalization. You state the enrollee's physician feels the enrollee needs the close medical supervision of impatient acute rehabilitation. The Plan denied your request. The Plan says the stay 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 the enrollee's nursing, medical and
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The enrollee was admitted for shortness of breath and had a pacemaker placed for cardiac
dysrhythmia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee
does 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.
There is not a reasonable expectation that this enrollee 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 IRF admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87640, 87481, 87798, 87653, 87801) rendered by the out-of-network (OON) provider on May 7, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal.

The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (87640, 87481, 87798, 87653, 87801) rendered by the out-of-network (OON) provider on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an aqueous drainage device (0191T).

You asked the Plan to pre-approve the insertion of an aqueous drainage device. You say that this device 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 the aqueous drainage device is indicated for enrollee's diagnosed with mild or moderate open-angle glaucoma. 

We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with severe glaucoma and does not have a covered diagnosis for the requested device. Based on this information, we decided that Medicare rules for coverage of the insertion of an aqueous drainage device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an aqueous drainage device (0191T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 12, 2021 by an out-of-network provider.
You asked the Plan to pay for physician services. You say that you were advised this provider was participating. The Plan denied your request. The Plan says you do not meet any of the exceptions listed in the handbook to use an out-of-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 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 services at issue in this appeal.
The Plan did not pre-approve the service at issue. The call history does not indicate that this provider's name was given. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services provided on July 12, 2021 by an out-of-network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the enrollee cannot do anything on her own. The Plan denied your request. The Plan says the enrollee is no longer having consistent meaningful benefits from skilled services.

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 services. Our physician reviewer found that the enrollee was at a contact guard assist for walking, bed mobility, and transfers. She was at supervision for eating, minimal assist for grooming, and maximal assist for bathing and dressing. She does not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of her condition. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87624, 88175) rendered by the out-of-network (OON) provider on May 5, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (87624, 88175) rendered by the out-of-network (OON) provider on May 5, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services have not been shown to be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, the criteria for continued acute inpatient mental health treatment for the dates in question of September 30, 2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided on May 27, 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 a $150 copayment for each covered diagnostic procedure or test at a network outpatient facility.

You have been asked to pay a $100 copayment for the outpatient diagnostic test provided at a network hospital facility, which is less than the applicable copayment. 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 breast ultrasound (76641) provided on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine magnetic resonance imaging.

You asked the Plan to pre-approve magnetic resonance (e.g., proton) imaging, spinal canal and contents,
lumbar, without contrast material (72148). You say that the enrollee needs an MRI. The Plan denied your
request. The Plan says the enrollee has not completed physical therapy.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 magnetic resonance (e.g., proton)
imaging, spinal canal and contents, lumbar, without contrast material (72148). Our reviewer says that the
requested lumbar MRI is not supported. Our physician reviewer found there was no detailed indication of
recent, comprehensive, and reasonable conservative treatment provided to this injured worker for the lower
back complaints. Therefore, the requested lumbar MRI is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar,
without contrast material (72148) have not been met. Therefore, we decided that the Plan does not have to preapprove
lumbar spine magnetic resonance imaging.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on March 19, 2021.

You asked the Plan to pay for the PET scan. You say that the services are covered by Medicare. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that CPT code 78815 was billed with a diagnosis code C50.911, malignant neoplasm of unspecified site of right female breast. We looked at the file and the rules. The billed diagnosis code is not among those indicated for coverage. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on March 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation represented by code 75726-26-59 and Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) represented by code 75774-26-59 x6 provided on March 2, 2021.
You asked the Plan to pay for codes 75726-26-59 and 75774-26-59 x6. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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 show that the services billed with the -59 modifier are distinct procedural services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have been met. Therefore, we decided that the Plan has to pay for the Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation represented by code 75726-26-59 and Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) represented by code 75774-26-59 x6 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.