Persius/hicric huggingface dataset:
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 meets Medicare guidelines for coverage of IRF care and the medical necessity to warrant that level of care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the enrollee's medical conditions appear stable and there are no wound care needs. The enrollee does not require medical oversight of her condition at an acute hospital level of care. There is a primary rehabilitation diagnosis of debility, which does not support the medial necessity of acute level rehabilitation. The enrollee requires physical therapy for mobility and endurance. There is no clear need or occupational therapy, and the enrollee does not require speech therapy services. The enrollee is limited by debility and the severity of her comorbid medical conditions with decreased endurance and shortness of breath. The enrollee would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at skilled nursing facility level. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the topical application of fluoride varnish (D1206) provided on October 3, 2019.You asked the Plan to pay forthe dental services. You say that your dentist advised you should have 2 cleanings per year. You say that you feel this should be covered.The Plan denied your request. The Plan says the frequency limit for prophylaxis has been exceeded. The Plan also says that the topical application of fluoride varnish is not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and prophylaxis is a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for this service on February 13, 2019. Additionally, the topical application of fluoride varnish is not a covered service.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110) and the topical application of fluoride varnish (D1206) provided on October 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled nursing and therapy needs, but they do not need to be provided on a daily basis. If stair climbing is an issue, this would most appropriately occur on the actual stairs in the home setting. Rearrangement of the living space (e.g. setting up a bed on the first floor) or use of adaptive equipment (e.g. commode) would be examples of ways in which a stair climbing deficit could be addressed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuing Skilled Nursing Facility (SNF) services.You asked the Plan to pre-approvethe SNF services.You say that ongoing SNF services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing PT and OT, the records do not support the need for services every day, or in the inpatient 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 pre-approvecontinuing Skilled Nursing Facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you on May 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the provider is not Medicare-certified.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe services rendered to you on May 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital services provided on January 23 -February 10, 2019.You asked the Plan to pay forthe inpatient hospital services. You say that the records provided support the care provided.The Plan denied your request. The Plan says the hospital failed to coordinate care with the plan once the enrollee's emergency medical condition was stabilized.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital services. Our reviewer says that the criteria for out-of-network services have not been met. Our physician reviewer found the enrollee had a history of right knee surgery with post-operative infection. On January 23, 2019, the treating orthopedist evaluated the enrollee and noted a wound infection. The enrollee was noted to be stable and in no acute distress. The enrollee's vital signs were stable and there were no signs of sepsis. The plan was for surgical incision and drainage, with cultures to guide therapy. After this initial evaluation completed by 10:50 AM on January 23, 2019, the enrollee was medically stable and could have been safely transferred by ambulance toan in network hospital. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.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 inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital services provided on January 23 -February 10,2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transcutaneous electrical nerve stimulation (TENS) device (E0720).You asked the Plan to pre-approvethis device. You say that the nerve stimulator is medically necessaryto provide assistance asyou feel your health and quality of life are hindered by your condition.The Plan denied your request. The Plan says this nerve stimulator deviceis not medically necessary.The Plan follows Medicare rules.Medicare rules say that aTENS device will be denied as not reasonable and necessary for acute pain (less than three months duration) other than for post-operative pain.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve this device. Ourreviewer says that you donot meet criteria for coverage of aTENS device. Our physician reviewer found that you havea diagnosis of a major depressive disorder. The electrical stimulation unit (E0720) at issue in this case is not medically reasonableand necessary for your condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met.Specifically, the TENS device has been requested forthe treatment of depression. However, Medicare covers a TENS device only for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain. Therefore, we decided that the Plan does not have to pre-approvea transcutaneous electrical nerve stimulation (TENS) device (E0720).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (82570, 83986, 81003) provided to the enrollee on August 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not separately reimbursable.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure codes 82570, 83986, and 81003, are part of edit pairs with procedure code 80307. Procedure code 80307 is a column one code, and procedure codes 82570, 83986, and 81003 arecolumn two codes. Procedure code 80307has been paid on this claim, which means that procedure codes 82570, 83986, and 81003arenot eligible for payment.Therefore, we decided that the Plan does not have to pay forthe services (82570, 83986, 81003) provided to the enrollee on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Eyeglasses and lenses (V2784, V2303) provided September 23, 2019.
You asked the Plan to pay for the full cost of the eyeglasses. You say that the eyeglasses should be covered. The Plan denied your request. The Plan says the cost exceeds the $150 allowance provided by the plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $150 per calendar year. We looked at the file and the Plan's rules. The total cost of the eyeglasses and lenses came to $309. This exceeds the $150 allowance provided by the plan contract. Therefore we decided that the enrollee is responsible for the amount in excess of the $150 allowance provided by the plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220), the core build up (D2950), and the 2D oral or facial photographic image provided on October 10, 2019.You asked the Plan to pay forthe intraoral x-ray, the core build up, and the 2D oral or facial photographic image. You say that after the crown is paid for, you should have roughly $500 of unused benefit left. You say that you should be able to use the benefit towards this procedure.The Plan denied your request. The Plan says the core build up and 2D oral or facial photographic image are not listed as covered services. The Plan also says that the frequency limit for intraoral x-rays 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, the core build up and 2D oral or facial photograph image are not among those covered under this benefit. Additionally, the frequency limit for intraoral x-rays has been exceeded. The record shows that the Plan previously paid for this service that you received on June 17, 2019.Therefore, we decided that the Plan does not have to pay forthe intraoral x-ray (D0220), the core build up (D2950), and the 2D oral or facial photographic image provided on October 10, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that people at the residential living facility where you live called for an ambulance even though you asked them not to. You say that you refused treatment when the ambulance and EMT team arrived because you had not wanted to deal with them in the first place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 6, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthenon-emergent ambulance transport to home (A0425, A0428) provided on May 29, 2019.  You asked the Plan to pay forthe transport. You say that the service was medically necessary.The Plan denied your request. The Plan says the transport was non-emergent and not preauthorized.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 contracted with the Plan. The Plan did not pre-approve the transport. The transport was non-emergent to the patient's home. 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 forthe non-emergent ambulance transport to home (A0425, A0428) provided on May 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs you received while you were an inpatient from August 19, 2019, to August 2, 2019.You asked the Plan to pay forthe drugs. The Plan denied your request. The Plan says the drugs are not covered.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 pay forthe drugs you received while you were an inpatient from August 19, 2019, to August 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
You asked the Plan to pre-approve HBO therapy. 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 coverage of hyperbaric oxygen therapy is limited to certain conditions. 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 HBO therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found in the case of this enrollee, the provided documentation states that this request for HBO therapy was intended to treat their non-healing surgical wound. The records and statements did not show evidence of this wound being a significant diabetic wound, having a severe infection to the bone or other indication which might justify HBO therapy. Therefore, this enrollee does not meet criteria, and the HBO therapy will be considered not medically 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 HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF would be the best option for the enrollee's recovery.The Plandenied your request. The Plansayscriteria for IRF care are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the member's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires speech therapy for communication and swallowing. She is ambulating greater than household distances and performing essential activities of daily living without hands-on assistance and there is no clear need for either physical or occupational therapy. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at an SNF level or through home-based and outpatient 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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on April 18, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that this doctor was not a back specialist and you should not have been referred to her for your back pain. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $35 copayment for each visit for Medicare-covered specialist services received in a network provider's office. You have been asked to pay a $35 copayment for the specialist officevisit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forthe specialist office visit provided on April 18, 2019.Your complaint about the poor service from the doctor is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 21, 2018.
You asked the Plan to pay for the train of four testing. 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 a covered benefit.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, separate payment for this service is not a covered benefit. The other neuromonitoring services rendered have been approved by the plan. Train of four testing is considered a bundled procedure and payment for this is included in the already-approved neuromonitoring. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 21, 2018.