Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hydraulic lift purchased from the OON
provider on March 30, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the item was purchased from 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 issue reimbursement 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 item at issue in this appeal. The Plan did not pre-approve the item at issue.
We found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided
that the Plan does not have to issue reimbursement for the hydraulic lift purchased from the OON provider on
March 30, 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 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 the member is receiving appropriate in-patient acute care and
does not require 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. There are no
complex medical or nursing needs. Intravenous medications and wound care can be safely done in a skilled
nursing facility or home setting with home health aide. An LTACH will not add any value based care. An
LTACH will not change short or long term outcome. An LTACH will lead to futile over treatment and will increase risk of complications. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine provided on August 30, 2021.
You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that this vaccine should be
covered by the Plan. The Plan denied your request. The Plan says this vaccine is not covered under Medicare
Part B.
The Plan follows Medicare rules. Medicare rules say that in the absence of injury or direct exposure to illness,
Medicare does not pay for or provide the shingles vaccine under Medicare Part B. The Plan contract states the
shingles vaccines are covered under Medicare Part D. The records do not show that you were being treated for
an aggravated outbreak of shingles. Therefore, we decided that the Plan does not have to pay for a shingles
vaccine provided on August 30, 2021 under the Medicare Part B benefit.
Benefits for the shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays
(D0274), and prophylaxis (D1110) provided on July 14, 2021, by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that
when you took out this policy, effective January 1, 2021, you were advised that this treating provider was in-
network. The Plan denied your request. The Plan says these services were performed by a non-participating
provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee
and the amount the provider bills you for the 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, you are responsible for a 50%
coinsurance for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) plus
the difference between the billed amounts and allowed amounts for the services being received OON. The Plan
also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120),
bitewing x-rays (D0274), and prophylaxis (D1110) provided on July 14, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 20,
2021 to July 19, 2021.
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF
services. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of
coverage.
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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided June 20, 2021 to July 19,2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on July 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (76705)
provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) to be
provided by a periodontist.
You asked the Plan to pre-approve services performed by a periodontist. You say that these services are
necessary. The Plan denied your request. The Plan says eligible dental services are only covered when they are
performed by a participating general dentist. Therefore, services performed by a periodontist are not covered.
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. Covered dental services must
be received from a participating general dentist.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided by a
periodontist are not among those covered under this benefit. Therefore, we decided that the Plan does not have
to pre-approve periodontal scaling and root planing (D4341) to be provided by a periodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that you are requesting a prior authorization
and in-network waiver for a MyoPro 2, Motion G orthotic device for purchase. The Plan denied your request.
The Plan says this item is considered experimental and investigational. There is insufficient evidence showing
it is safe, effective and provides health benefits. Enrollee's must receive their medical services from an innetwork
provider
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 preapprove
the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing (CPT code(s):
81162, 81206, 81292, 81295, 81298, 81301, 81311, 81317) provided to the enrollee on May 4, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not covered as billed by the provider.
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 testing have not been met. The enrollee had molecular cancer
genomics (CGx) testing on May 4, 2020. The denial remains upheld as non-covered as Medicare denies
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be
submitted for the panel. Therefore, we decided that the Plan does not have to pay for molecular cancer
genomics (CGx) testing (CPT code(s): 81162, 81206, 81292, 81295, 81298, 81301, 81311, 81317) provided to
the enrollee on May 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October
27, 2020, to November 5, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says home health agencies must report a line item with the same revenue code and date of
service as the first billed visit, reporting one of three Q codes Q5001, Q5002 or Q5009, describing the location
where services were done. The Plan states the claim submitted has an invalid Q code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an issue with the reported Q code. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from
October 27, 2020, to November 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 21, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you cannot afford 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 $120
copayment for emergency room visits.
You have been asked to pay a $120 copayment for the ER 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 emergency room (ER) visit you had on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computer tomography coded 70450 provided on July 15, 2021.
You asked the Plan to pay for the computer tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 70450 for the computer tomography is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computer tomography coded 70450 provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pulmonary function test you had on July 26, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you told the office that any test not covered by insurance was not to be done. The billing office should have known what was covered. You said that you did not sign anything authorizing this test. The Plan denied your request. The Plan says this test was covered, but the $20 represents your applicable copayment.
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 $20 copayment for non-radiological diagnostic services. You have been asked to pay a $20 copayment for the pulmonary function test. The pulmonary function test falls within the non-radiological diagnostic 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 pulmonary function test you had on July 26, 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 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 the member is receiving appropriate in-patient acute care and
does not require 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. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan.
You asked the Plan to pre-approve Lumigan. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Lumigan is not covered under the enrollee's Part B benefit.
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 Lumigan.
Benefits for Lumigan 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: 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 surgical repair of a hip fracture after a fall in July 2021 and have been living at home. There are complaints of weakness. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (CT) provided to the enrollee on July 16, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a covered diagnosis.

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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found in order for CT perfusion to be covered, the guidelines require that a large or medium-sized vessel must be occluded such that brain perfusion distal to the blockage may be assessed to analyze the penumbra of the ischemic area. Since the computed tomographic angiography (CTA) of the head and neck were negative, the medical necessity of the CT brain perfusion was not established. 

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 have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (CT) provided to the enrollee on July 16, 2021.