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

We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis without contrast (74176).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested service have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. Our reviewer says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found that the requested follow-up CT scan was recommended at a 6-month interval after a prior CT scan that discovered a mildly enlarged left inguinal lymph node. 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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis without contrast (74176).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320) and cone beam CT capture
(D0364) provided on June 16, 2021.

You asked the Plan to pay for the endodontic therapy (D3320) and cone beam CT capture (D0364). You say
that you did not have a root canal performed on this tooth before this date. You say that you request review of
the claim and approval of payment. The Plan denied your request. The Plan says The contract says that
endodontic therapy is covered once per tooth per lifetime and the cone beam CT capture 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, you also have a maximum benefit of
one endodontic therapy procedure per tooth per lifetime. The Plan received the claim for the endodontic
therapy for tooth #13 provided on July 1, 2021 prior to this claim. The endodontic therapy provided on July 1,
2021 was paid for, which exhausted your benefit. The cone beam CT capture (D0364) remains denied as a noncovered
benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3320)
and cone beam CT capture (D0364) provided on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by an out-of-network provider on March 10, 2021, to March 13, 2021.
You asked the Plan to pay for inpatient hospital care. You say that this should be revised to acute kidney failure with tubular necrosis as per the documentation and coding guideline. The Plan denied your request. The Plan says medical records do not support the billing of - N17.9: acute kidney failure, unspecified as principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with N17.9: acute kidney failure, unspecified as principal diagnosis. 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 inpatient hospital care. Our reviewer says that acute kidney injury is sequenced as the third diagnosis. Our physician reviewer found the clinical documentation indicated that cellulitis and wound care were the primary diagnosis treated during the admission. The review has determined that the medical records did not support the billing of - N17.9: acute kidney failure, unspecified as principal diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided by an out-of-network provider on March 10, 2021, to March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a urine PCR screening panel provided to the enrollee on April 20, 2021.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this type of testing is considered unproven and not medically necessary.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered unproven and not medically necessary. The review has determined that the services at issue in this case were not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have
to pay for a urine PCR screening panel provided to the enrollee on April 20, 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 this admission is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for long term acute care
services.
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 does not require services at the LTACH that are not available at the acute
care hospital where he is currently receiving care. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and this care is able to be furnished
safely and effectively only on an inpatient basis.
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 pay for an office visit provided on June 29, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for office visit. You say that you had a visit with the same doctor that processed as in-network on March 26, 2021. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an office visit provided on June 29, 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 anesthesia services (99153) provided on June 10, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting.
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision care provided on June 14, 2021.
You asked the Plan to waive the deductible for vision care. You say that you are receiving ongoing treatment and the visits keep getting denied. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible which applies to out-of-network vision care. You received vision care on June 14, 2021, from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had paid $84.14 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $122.45.
The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to vision care. This cost sharing is a contractual obligation that had not been met at the time vision care was received on June 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for vision care provided on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110), the manual therapy (97140), and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on July 7, 2021 and July 9, 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 therapeutic exercises (97110), the manual therapy (97140), and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on July 7, 2021 and July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electroacupuncture procedure for chronic low-back pain.
You asked the Plan to pre-approve an electroacupuncture procedure. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that acupuncture is covered for Medicare patients with cLBP when administered by specified medical personnel. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electroacupuncture procedure have not been met. Specifically, the request is for a device that is designed to stimulate acupuncture points to relieve pain. Acupuncture for low back pain is only covered as a professional treatment performed by a properly credentialed provider.
The Medicare benefit does not extend to placement of an automatic stimulator. Therefore, we decided that the Plan does not have to pre-approve an electroacupuncture procedure for chronic low-back pain.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on February 13, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says that this was billed with place of service 81 when place of service 11 should have been
reported.
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 states that the service at issue was billed with place of service 81, but
the claim form included in the file shows it was billed with place of service 11. The Plan has not provided
information showing that this place of service is not correct. Therefore, we decided that the Plan has to pay for
drug testing (G0483) provided on February 13, 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 pre-approve the MyoPro Motion G orthotic device (L8702) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro 2 represents this enrollee's best opportunity for regaining meaningful use for her left upper limb and has been deemed medically necessary for this enrollee by her provider. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on November 5, 2020.
You asked the Plan to pay for the testing services. You say that venous dopplers are covered by Medicare when medically necessary. The Plan denied your request. The Plan says the documentation does not support an additional study.
The Plan must follow Medicare rules. Medicare rules say that claim lines that have been determined to be exact duplicates of another claim are denied.
In this case, the CPT Code Manual definition of code 93971 is duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. We find that CPT code 93971 billed with modifiers -26 and -RT, was previously billed and paid for by the plan. Duplicates of another claim are not covered. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - new or established patient (D0150) provided March 4, 2021, and the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and alveoloplasties in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided April 2, 2021, by an out-of-network (OON) provider.

You asked the Plan to provide additional payment for the comprehensive oral exam, tooth extractions and alveoplasties. You say that you do not have a closer dentist in your area. The Plan denied your request. The Plan says the dentist is out of network and the services were not pre-approved. The claims and associated cost-shares have processed correctly.

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. The Plan covers the comprehensive oral exam with 0% coinsurance, tooth extractions with 55% coinsurance and alveoplasties with 75% coinsurance when provided OON. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. 

We looked at the file and Medicare rules. The Plan provided documentation showing that the services were processed with the correct coinsurance applied. The OON provider may bill for any amount greater than the payment made by the Plan to the provider. The Plan had in-network providers who could perform the services at issue. Based on this information, we decided that the Plan's has processed the claims correctly. Therefore, we decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - new or established patient (D0150) provided March 4, 2021, and the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and alveoloplasties in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided April 2, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. 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 selfadministered
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 Ubrelvy for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 7, 2021.

You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 services provided on July 7, 2021 by an out-of-network (OON) provider.
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for routine transportation provided on May 24, 2021.

You asked the Plan to pay for the routine transportation. You say that the rehabilitation center chose the transport company. The Plan denied your request. The Plan says transportation services must be provided by our vendor.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when provided by the Plan's vendor 

We looked at your request, the records in the case file, and the rules. The file shows that the transportation was no provided by the Plan's vendor. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for routine transportation provided on May 24, 2021.