Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from April 14, 2021 through April 21, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the daily notes show what kind of precautions were taken by the provider prior to treating the patient. You say that the medical records fully support billing code 99072 and the code should be reprocessed for payment. The Plan denied your request. The Plan says this is a bundled code and is not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from April 14, 2021 through April 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on March 10, 2021.
You asked the Plan to pay for psychotherapy, 30 minutes with patient (90832). You say that your physician provided medically necessary services to the member in good faith. The Plan denied your request. The Plan says there was no documentation of contact with the attending/primary care physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation of consent/declination or consultation with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy, 30 minutes with patient (90832) have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on May 24, 2021 by an out-of-network provider.
You asked the Plan to pay for the chest x-ray (71046). You say that the enrollee was not aware he had to change his doctor due to the new insurance plan. The Plan denied your request. The Plan says you did not request prior authorization as required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on May 24, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve additional skin substitute treatments.
You asked the Plan to pre-approve the additional treatments. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the additional treatments. Our reviewer says that the requested additional treatments are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had a left lower leg wound that after failing conservative therapy was treated with a skin substitute. The record indicates that the wounds has decreased in size from 190 cm3 to 12.5 cm3. The record indicates that there has been significant improvement in the wound and continued application is medically necessary and reasonable, as defined by Medicare rules. The elements of the coverage criteria are satisfied. 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 additional treatments have been met. Therefore, we decided that the Plan has to pre-approve additional skin substitute treatments.
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 pre-approve a second bilateral facet medial branch block at lumbar level L4-L5.
You asked the Plan to pre-approve a second bilateral facet medial branch block at lumbar level L4-L5. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and necessary when specific criteria is met. 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 second bilateral facet medial branch block at lumbar level L4-L5. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the enrollee had a 60% reduction in pain after the first medial branch nerve block (MBBs) at L4-L5. Per the coverage criteria, repeat thermal facet joint radiofrequency ablation (RFA) at the same anatomic site is considered medically reasonable and necessary provided the enrollee had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living (ADLs) as compared to baseline measurement using the same scale. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 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 second bilateral facet medial branch block at lumbar level L4-L5 have not been met. Therefore, we decided that the Plan does not have to pre-approve a second bilateral facet medial branch block at lumbar level L4-L5.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January
6, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.

The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels,
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or
documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel
is not covered. 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 the cardiovascular risk assessment panel
provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with gastroenterology for the enrollee.

You asked the Plan to pre-approve the office visit. You say that this is medically necessary, as it is a follow-up from emergency services rendered. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has not met the limits set in the subscriber agreement.

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 office visit. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee gastric cancer for which surgical and oncologic care are appropriate. Relative to the enrollee's presenting upper gastrointestinal bleeding, hemostasis of her formerly bleeding cardia ulcer has proved durable. As such, there is no urgent nor emergency care needed for out-of-network follow-up nor intervention. The enrollee's family prefers that the enrollee return to the requested provider for telemedicine follow-up.

However, sufficient in-network expertise and availability exists for post-hospital gastrointestinal care. An in-network telemedicine gastroenterology follow-up indeed has already been scheduled and pre-authorized. 

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 office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit with gastroenterology for the enrollee.
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 the enrollee is in the hospital and the doctors want him to get started with his treatment as soon as possible. You say that the enrollee's doctors feel that LTACH care is needed for the enrollee to heal. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the services needed could be provided in another setting.
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 [state the medical finding(s) upon which the physician based his/her conclusion] 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit 
(99284) provided on May 12, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that your 
previous insurance would have covered the full cost of this service. The Plan denied your request. 
The Plan says this service processed 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 $90 copayment for emergency services.  
 
You have been asked to pay a $90 copayment for an emergency room 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 an emergency room 
visit (99284) provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), sphere lenses (V2100) and
polycarbonate lenses (V2784) provided on April 2, 2021.
You asked the Plan to pay for eyeglass frames, sphere lenses and polycarbonate lenses. You say that you do not
agree with the denials and would like to request reconsideration. The Plan denied your request. The Plan says
you exhausted your allowed benefit.
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 contract says that you receive a $150 allowance every two years with the Plan's specified
routine vision provider.
We looked at the file and the Plan's rules. The records show that you purchased eyeglass frames which resulted
in a $0 copayment. The records also show that the sphere lenses and the polycarbonate lenses were all upgrades
which are not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of
eyeglass frames, sphere lenses and polycarbonate lenses have not been met. Therefore, we decided that the Plan
does not have to pay for eyeglass frames (V2020), sphere lenses (V2100) and polycarbonate lenses (V2784)
provided on April 2, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the
requested imaging is medically reasonable and necessary. Our physician reviewer found this can be approved
as initial staging (restaging) for non-small-cell lung cancer, per the 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve
a PET/CT scan for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve tertiary care with an out of network (OON) provider.
You asked the Plan to pre-approve the OON tertiary care. You say that you were recently diagnosed with pancreatic cancer. You say that you have diarrhea daily and cannot sit in a car for 2 hours to go to chemotherapy treatment. You say that you are already feeling weak and you do not know how you will feel after treatment. You say that the requested OON tertiary level of care facility is located closer to your home than the network locations the Plan has referred you to. The Plan denied your request. The Plan says that the two referenced network tertiary facilities are equipped to provide the same level of care as the requested OON tertiary facility.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The provider is a non-contract provider. The network tertiary providers that the Plan has referred you to are not located within reasonable distance and travel time from your home. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve tertiary care with an out of network (OON) provider.
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 pre-approve facet radiofrequency ablation on your neck.
You asked the Plan to pre-approve facet radiofrequency ablation on your neck. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region.
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 facet radiofrequency ablation on your neck. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the records show the enrollee had two sessions of radiofrequency ablation (RFA) of the thoracic spine within the past 12 months: RFA of the right cervical spine (C6-T1) on March 19, 2021 and RFA of the left cervical spine (C6-T1) on February 4, 2021. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet radiofrequency ablation on your neck have not been met. Therefore, we decided that the Plan does not have to pre-approve facet radiofrequency ablation on your neck.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care beyond September 22, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically reasonable and necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care are no longer met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 90-year-old female with diabetes, dementia, cerebrovascular accident, and urinary tract infection. In this case, the enrollee received covered SNF care until September 22, 2021, and is now requesting a continuation of these services. At this time, there are no identifiable skilled nursing needs and no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, the beneficiary 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care beyond September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0272) provided on April 9, 2021.

You asked the Plan to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0272). You say that you were told to seek a second opinion, but the claim was denied at the other provider. The Plan denied your request. The Plan says the frequency limit has been exceeded.

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 comprehensive oral evaluation every three plan years and one bitewing x-ray every year. The Plan paid for the comprehensive oral evaluation and bitewing x-rays provided on January 14, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0272) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on March 11, 2021.
You asked the Plan to pay for eyeglass frames, progressive lenses and anti-reflective coating. You say that you have received services from this provider in the past and you did not know they were no longer in-network. The Plan denied your request. The Plan says you are responsible for all costs for eye wear purchased from an out-of-network provider.
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 contract says that you receive one purchase of eyeglass lenses and frames and disposable or conventional contact lenses every 2 calendar years. You must see an in-network vision provider to receive routine vision benefits. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on March 11, 2021.