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

We decided that the Plan does not have to pay for individual psychotherapy (90834) provided on June 24,
2021, by an OON provider.

You asked the Plan to pay for the psychotherapy services. You say that you are requesting for review of the
documents and process the claim for payment. 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 non-contracted 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 individual psychotherapy (90834) provided on
June 24, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist orthosis (L3908), provided on April 8, 2021.

You asked the Plan to pay for the wrist orthosis. You say that the item should be covered. The Plan denied your request. The Plan says there is no documentation indicating a face-to-face encounter.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain valid and relevant medical records which support medical necessity for the supplies provided in this case. There is no documentation indicating the enrollee had a face-to-face encounter. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist orthosis (L3908), provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 28, 2021.  You asked the Plan to pay for the dental service. You say that you have been receiving this service for the last 10 to 15 years. You also say that insurance has always covered this. The Plan denied your request. The Plan says the periodontal maintenance is not listed as 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 periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 8, 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 are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on April 23, 2021, and May 17, 2021.  You asked the Plan to pay for the services. You say that you want to continue seeing this provider. The Plan denied your request. The Plan says the services were not authorized.  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 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 services provided to you by an out-of-network provider on April 23, 2021, and May 17, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the tissue exam provided October 22, 2020.  You asked the Plan to pay for the services provided. You say that the clinical notes support medical necessity. The Plan denied your request. The Plan says that the claim was processed correctly.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  We looked at the file and the rules. The case file does not specify what information was required by the Plan for them to adjudicate the services at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the tissue exam provided October 22, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218), provided on May 17, 2021.  You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item should be covered. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218), provided on May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee's health.
The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (92014) provided by an out-of-network provider on July 12, 2021  You asked the Plan to pay for the eye exam. You say that you would like reconsideration because you did not know that you had to receive the eye exam from a network provider. The Plan denied your request. The Plan says this service was rendered out-of-network so you are responsible for the entire cost.  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. The Plan does not cover routine eye exams when rendered out-of-network.  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 eye exam have not been met. Specifically, the record indicates that you received the routine eye exam from an out-of-network provider. The Plan does not cover routine eye exams when provided out-of-network. The contract with the Plan clearly states that you are responsible for the entire cost of this service. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) provided by an out-of-network provider on July 12, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam with refraction provided by an out-of-network provider on June 23, 2021.  You asked the Plan to pay for the eye exam with refraction. You say that you were told this provider was an acceptable place for hearing aids, so you assumed it was for eye care too. You say that you have been satisfied with care from the Plan in the past and the eye exam should be reimbursed. The Plan denied your request. The Plan says this service is not covered 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. The Plan covers these services when they are received from a network provider.  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 eye exam with refraction have not been met. Specifically, the service is not covered when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the eye exam with refraction provided by an out-of-network provider on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthetic agent injection provided on February 5, 2021.  You asked the Plan to pay for injection service. You say that you are appealing with the anesthesia record. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is included in code 01402 and is not separately reimbursable.  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 64447 is injection(s), anesthetic agent(s) and/or steroid; femoral nerve.  We asked our coder 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 injection service. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found under certain circumstances, an anesthesia practitioner may separately report an epidural or peripheral nerve block injection for post-operative pain management when the surgeon requests assistance with post-operative pain management. However, the records submitted do not support that a femoral nerve block was performed at the request of the surgeon for post-operative pain management.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection service have not been met. Therefore, we decided that the Plan does not have to pay for anesthetic agent injection provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the dermatology visit you had on  July 19, 2021.  You asked the Plan to waive the copayment for the dermatology visit. You say that the doctor did not say anything to you, so you don't think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  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 $50 copayment for specialist visits.         You have been asked to pay a $50 copayment for the dermatology visit. The medical records confirm that you did have an office visit on this date.  This copayment applies regardless of your satisfaction with the services received. 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 dermatology visit you had on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5261) and the hearing aid accessory (V5267), provided on April 26, 2021.  You asked the Plan to pay for the hearing aids and accessory. You say that the service should be covered. The Plan denied your request. The Plan says you did not contact the Plan prior to the purchase of your hearing aid.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained through the Plan's network.   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 hearing aids and accessory have not been met. Specifically, you did not obtain these services in the Plan's network. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) and the hearing aid accessory (V5267), provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not require an intensive rehabilitation program to return to pre-admission baseline.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for infected bilateral foot ulcers. The enrollee's 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 patient has a need for physical and/or occupational therapy, there is no documentation of 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a breast ultrasound.

You asked the Plan to pre-approve a breast ultrasound. You say that the services are necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.

The Plan follows Medicare rules. Medicare rules say that certain ultrasound diagnostic procedures are 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 a breast ultrasound. Our reviewer says
that the services are medically necessary. Our physician reviewer found such a recommendation is standard of
practice in breast imaging when a mass is detected on mammography requiring further evaluation. No physical
findings need to be present to warrant further imaging evaluation and ultrasound is the next step.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a breast ultrasound have been met. Therefore, we decided that the Plan has to
pre-approve a breast ultrasound.

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from January 19, 2020, to February 17, 2020.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period from October 23, 2019 to February 2, 2020. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 19, 2020, to February 17, 2020.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from July 1, 2016, through July 22, 2016, billed Resource Utilization Group (RUG) codes RUB20 (7 units) and RUB0D (14 units).  You asked the Plan to pay for the SNF stay as billed. You say that this was billed correctly, and there are no Medicare rules which support that electrical stimulation as done in a SNF is an unskilled service. The Plan denied your request. The Plan says that the documentation does not identify how much of the time recorded as performing electrical stimulation was actually skilled. Therefore, the RUG code for 7 days of this claim is not justified and was reduced.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a clearly justified denial rationale for the services at issue. It is noted that the Change of Therapy (COT) assessment performed on July 14, 2016 did not accurately document only the amount of skilled therapy time since the documentation did not differentiate between skilled vs unskilled electrical stimulation (unattended). The documentation shows that 20 minutes of this service was done on various dates during the assessment period. The Plan has not provided an explicit Medicare regulation which justifies that time spent with this therapy modality is unskilled. The provider on the other hand has submitted an opinion letter from the American Physical Therapy Association (APTA) which states that electrical stimulation as done by therapists in a SNF setting does qualify as a skilled service. As such, we find that the time documented as being spent on this treatment is correctly reported and cannot be used to change the RUG code for these dates. We find that the Plan's adjustment to the SNF payment is not substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from July 1, 2016, through July 22, 2016, billed Resource Utilization Group (RUG) codes RUB20 (7 units) and RUB0D (14 units).   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 pay for a sling provided April 9, 2021.  You asked the Plan to pay for a sling. You say that the orthopedic center charged you for a sling out of pocket. You tried to submit to the Plan the out-of-pocket expenses and was told that you should have not paid for anything. The Plan denied your request. The Plan says this item is not covered under the Plan benefits.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a sling is an OTC item. Therefore, we decided that the Plan does not have to pay for a sling provided April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oximeter (E0445), purchased on June 17, 2021.  You asked the Plan to pay for the oximeter. You say that the service is medically necessary. The Plan denied your request. The Plan says purchased oxygen accessories are statutorily non-covered.  The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pay for the oximeter (E0445), purchased on June 17, 2021.