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

We decided that the Plan does not have to pay for the office visit (99204), motion fluoroscopic evaluation of swallowing function by cine or video recording (92611), radiologic examination of swallowing function (74230), x-ray exam of the cervical spine (72040), x-ray exam of the jaw (70100), x-ray exam of teeth (70310), radiologic exam of the chest (71045), and the radiologic exam of the upper gastrointestinal tract (74240) rendered by the out-of-network (OON) provider on April 20, 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 office visit (99204), motion fluoroscopic evaluation of swallowing function by cine or video recording (92611), radiologic examination of swallowing function (74230), x-ray exam of the cervical spine (72040), x-ray exam of the jaw (70100), x-ray exam of teeth (70310), radiologic exam of the chest (71045), and the radiologic exam of the upper gastrointestinal tract (74240) rendered by the out-of-network (OON) provider on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 36415, 80061, 80053,
85025, 83036) provided to the enrollee on May 5, 2021, by an out-of-network provider.

You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The
Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a
network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 laboratory services (CPT code(s): 36415,
80061, 80053, 85025, 83036) provided to the enrollee on May 5, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on March 26, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service was not billed by Medicare coding regulations.
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT code 99153 is not payable as billed. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0675 and E0673),
provided on February 1, 2021.
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by
Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device
(E0675 and E0673), provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to metal crown for tooth #9.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says the tooth does not have significant breakdown necessitating a crown.
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 dental services. Our reviewer says that the requested dental services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for a crown on endodontically treated #9. The tooth appears to have only an endodontic access and no other restorations. You have also said that the tooth was experiencing heat and cold sensitivity. The tooth appears to be adequately sealed endodontically and should not be experiencing any temperature sensitivity, though a nearby tooth may be reacting to the stimuli. An endodontically treated anterior tooth that has only endodontic access cut into it does not require to have a full coverage crown for long term viability. It is noted that there is about 45% bone loss on #9 as well, with other areas of the mouth are exhibiting notable areas of bone loss. Given the lack of structural damage to the tooth aside from the required endodontic access, there is no medical necessity for a crown on tooth #9. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to metal crown for tooth #9.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 19, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says rules for SNF care are no longer met.
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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 81-year-old female who was admitted to the acute care hospital on August 15, 2021, with hypertension. You were then in a SNF until September 19, 2021, and are requesting additional SNF care. Based on the documentation provided, it is my opinion that you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. At this point, your care needs are custodial and, as a practical matter, can be provided at a lower level of 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the services should be processed at out-of-network rates. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 lab 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 lab services provided on April 20, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 file shows the enrollee was seen for a medication refill. 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 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 office visit provided on May 7, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or 
hospice settings (G0156) and direct skilled nursing services of a RN (G0299). 
 
You asked the Plan to pre-approve the services of home health/hospice aide and direct skilled nursing services 
of a RN. You say that the enrollee suffers from Alzheimer's, and you have to go back to work so there will be 
no one in the home to care for the enrollee during the day. The Plan denied your request. The Plan says the 
enrollee does require assistance with basic activities of daily living, but there is no evidence that the enrollee 
needs skilled nursing care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services of home health/hospice 
aide and direct skilled nursing services of a RN. Our reviewer says that the requested services are not shown to 
be medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or skilled therapy needs. Our reviewer also found that the enrollee's care needs appear to 
be custodial. 
 
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 services of home health/hospice aide and direct skilled nursing services of a 
RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home 
health/hospice aide in home health or hospice settings (G0156) and direct skilled nursing services of a RN 
(G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over acute hospital. 
 
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. The patient 
appears to be more stable, but he still requires only short-term additional acute care which can safely be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that are not already available and covered 
at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 30, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you believe this claim is one for only 
a second procedure and is covered by the Plan. The Plan denied your request. The Plan says the contract 
provides benefits for this procedure twice in a benefit period. 
 
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, routine preventive teeth cleanings are 
limited to a maximum of 2 per calendar year. The record shows that the enrollee received a periodontal 
maintenance (D4910) on January 28, 2021, and February 10, 2021 and the enrollee's routine preventive teeth 
cleaning benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided to the enrollee on March 24, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The ordering provider did not confirm the order for genetic testing. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided to the enrollee on March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on December 3, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the x-ray. You say that the facility did not provide your office with the information needed to get the claim paid. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the x-ray provided on December 3, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the breast (77049) provided March 25, 2021.

You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI) of the breast. You say that you were not aware you would be charged a copayment for this service. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $325 copayment for diagnostic radiology services. 

You have been asked to pay a $325 copayment for the magnetic resonance imaging (MRI) of the breast. This service falls within the diagnostic radiology services 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 the magnetic resonance imaging (MRI) of the breast (77049) provided March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on March 1, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found there is insufficient data to suggest that the enrollee is checking blood glucose levels four times per day and adjusting insulin doses according to the blood glucose levels. There is no documentation in the office note or blood glucose log to support the criteria are met. There is also no documentation that the enrollee is adjusting insulin dosing with a sliding scale according to blood glucose levels. The services were therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on March 1, 2021.