Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the gastroenterology visit you had on June 15, 2021.  You asked the Plan to waive the copayment for the gastroenterology visit. You say that because your radiology report was read incorrectly, you should not 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 visits with a specialist.   You have been asked to pay a $50 copayment for the gastroenterology visit. This copayment applies regardless of the reason for the visit. 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 gastroenterology visit you had on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction (D7210), blood concentrate (D7921 x 2), bone replacement graft (D7953), initial 15 minutes of deep sedation (D9222), additional 15 minutes of deep sedation (D9223 x 2), and therapeutic parenteral drugs (D9216) provided on August 11, 2021.  You asked the Plan to pay for the dental services. You say that the provider listed on your denial letter is not a dentist that you have ever seen before. The Plan denied your request. The Plan says the provider listed on the claim is not a network provider. The Plan says that dental services performed out of network are not covered. The Plan also says that the bone replacement graft and blood concentrate are not listed as covered services.  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 bone replacement graft and blood concentrate are not among those covered under this benefit. Additionally, although the extraction, sedation services, and therapeutic parenteral drugs are covered, the record shows that the services were provided by an out of network dentist. The Evidence of Coverage clearly states that services obtained from vendors outside this network are not covered. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), blood concentrate (D7921 x 2), bone replacement graft (D7953), initial 15 minutes of deep sedation (D9222), additional 15 minutes of deep sedation (D9223 x 2), and therapeutic parenteral drugs (D9216) provided on August 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medications rendered on January 7, 2021.  You asked the Plan to pay for these services. You say that you could not travel back to the United States due to travel restrictions. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that drugs sold outside of the United States are excluded from coverage. The Plan follows this same rule.  We looked at the file and Medicare rules. The file shows that you received prescription drugs while outside of the United States. These services are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the medications rendered on January 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the psychotherapy service (90832) provided on February 4, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service was rendered by an out of network provider, without prior authorization. Additionally, the provider must attempt to consult the primary care physician about the services furnished and document the consent or declination date in the medical record.  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. Specifically, the record shows that this claim was billed by a Clinical Social Worker. Of note, Clinical Social Workers are not required to communicate with the member's primary care physician. The Plan has not forwarded any evidence to substantiate why this service does not meet Medicare criteria for coverage. It is the burden of the Health Plan to substantiate their denial with evidence.  In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the psychotherapy service (90832) provided on February 4, 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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 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 procedure codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.       We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the records show that a urine specimen was collected and not through venipuncture. 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 laboratory services rendered on March 22, 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 you would like an LTACH admission covered. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH.  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 that you are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and 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: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for the physical therapy services (97110, 97112, 97116 and 97530) provided on June 29, 2021, through July 16, 2021.  You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration because this is not a home health agency claim. The Plan denied your request. The Plan says that there is a more appropriate CPT code to bill for the rendered services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   We find that CPT codes 97110, 97112, 97116 and 97530 are supported in the record. Specifically, the record indicates these services were not rendered as part of a home health plan of care. It is appropriate for physical therapists to render services in the member's home. There is no evidence that this claim has been billed incorrectly.  Based on this information, we decided that Medicare rules for coverage of the physical therapy services have been met. Therefore, we decided that the Plan has to pay for the physical therapy services (97110, 97112, 97116 and 97530) provided on June 29, 2021, through July 16, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D3431).  You asked the Plan to pre-approve the biologic materials. You say that your tooth is attached to a nerve. You also say that you have pain in the tooth and have issues eating and drinking. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D3431).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for respiratory failure and pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.    Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has age-related osteoporosis, diagnosis confirmed with bone density testing. The documentation does not support that the enrollee has tried and failed zoledronic acid. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet step therapy criteria.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Reclast.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.  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 Reclast is not medically necessary; however, there are no medical records for review. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve Reclast.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc One.  You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that Synvisc One is only covered for certain indications.  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 Synvisc One. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has chronic left knee pain due to osteoarthritis. The enrollee takes Acetaminophen, Duloxetine, Ibuprofen, Hydrocodone, Tramadol, and topical Voltaren gel. The enrollee is status post a left knee intra-articular dexamethasone injection and status post a Synvisc injection. The x-ray of the left knee reported a possible small joint effusion. The documentation does not confirm a diagnosis of osteoarthritis of the left knee (by x-ray, computerized tomography (CT) scan, magnetic resonance imaging (MRI), nor ultrasound). There was no documentation of physical therapy or a home exercise program. In addition, the provider has only documented one (1) injection of intra-articular corticosteroid to the enrollee's left knee. Therefore, the enrollee does not meet criteria for the requested 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 Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4267), surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), abutment supported cast metal crown (D6062), implant supported porcelain/ceramic crown (D6065), and an implant supported crown (D6066).  You asked the Plan to pre-approve the guided tissue regeneration, endosteal implant, custom fabricated abutment, abutment supported cast metal crown, implant supported porcelain/ceramic crown, and an implant supported crown. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a guided tissue regeneration (D4267), surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), abutment supported cast metal crown (D6062), implant supported porcelain/ceramic crown (D6065), and an implant supported crown (D6066).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a follow up appointment to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the appointment. You say that you were approved in 2020 for a second opinion consultation with Boston Medical Center and would like to have a follow up appointment with them. The Plan denied your request. The Plan says they have provided a list of In-Network qualified providers that provide for 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 a follow up appointment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that this is a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says it has not been shown to be safe and effective in long-term studies.  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 requested services. Our physician reviewer found that interspinous stabilization devices remain experimental. More research is needed to show its safety and efficacy. Therefore, the requested services are not considered medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
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 enrollee will not be able return to independent living unless she has IRF care. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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 inpatient rehabilitation facility (IRF) admission and services.