Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 18, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care continues to be medically necessary. The Plan denied your request. The Plan says the criteria for coverage are no longer met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric care. Our reviewer says that inpatient psychiatric care is not medically necessary and reasonable from August 18, 2021, forward. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 18, 2021, forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 18, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (67904) provided March 8, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 67904 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (67904) provided March 8, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot wait thirty (30) days laying in a hospital. You state due to being in bed from the time of your surgery and fall, you have not been able to walk. You state you need impatient therapy to learn to walk again. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for supraventricular tachycardia and hypertensive urgency. 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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. 

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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899), and to pay more for the mandibular immediate denture (D5140), and three simple extractions (D7140 x3) provided on March 31, 2021.

You asked the Plan to pay for the removable prosthodontic procedure, or pay more for the mandibular immediate denture, and simple extractions. You say that you were told by a representative that these services would be covered. The Plan denied your request. The Plan says the removable prosthodontic procedure is not a covered service under your plan. The Plan also says that you pay a 50% coinsurance for Class 3 Major Services, and a 20% coinsurance for Class 2 Major 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 unspecified removable prosthodontic procedure (D5899) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for the mandibular immediate denture (D5140), and a 20% coinsurance for each simple extraction (D7140). The Plan also offers a $1,000 calendar year maximum. The record shows that you met the annual maximum benefit while processing this claim for the March 31, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899), and to pay more for the mandibular immediate denture (D5140), and three simple extractions (D7140 x3) provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225), and 
a partial lower denture with flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you are experiencing discomfort. You say 
that you are not able to eat or chew properly. You also say that you it is your understanding that extractions and 
partial dentures are covered under your plan. The Plan denied your request. The Plan says partial dentures with 
flexible base 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 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 
partial upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray and the inpatient admission provided from January 20, 2021, to January 23, 2021.

You asked the Plan to waive the copayments for the x-ray and the inpatient admission. You say that the enrollee was told that she should not be responsible for any copayment amounts. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment per encounter for x-rays and ultrasounds and a $200 copayment per day for days 1-7 of a hospital stay. 

The enrollee has been asked to pay a $20 copayment for the x-ray and a $200 copayment per day for the inpatient admission. ($200 x 3 days = $600). The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The inpatient admission falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the x-ray and the inpatient admission provided from January 20, 2021, to January 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (29823) provided October 7, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for this service was bundled in payment for another 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. 
 
We find that CPT code 29823 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, CPT Codes 29827 and 29823 have the same Endobase of 29805. Payment for CPT 29823 is 
bundled. Based on this information, we decided that Medicare rules for coverage of the surgical services have 
not been met. Therefore, we decided that the Plan does not have to pay for surgical services (29823) provided 
October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87633) provided January 22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. More than 5 pathogens were tested. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633) provided January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology consultation to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an ophthalmology consultation to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L1970, L2275, L2820) provided January 20, 2021.
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the claim was submitted without a needed modifier.
The Plan must follow Medicare rules. Medicare rules say that Claims lines billed with codes for Ankle-Foot or Knee-Ankle-Foot orthoses without a KX, GA or GZ modifier will be rejected as missing information.
We looked at the file and Medicare rules. The code billed did not include the required KX modifier. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L1970, L2275, L2820) provided January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (31615, 31502) provided November 17, 2020.

You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. 

In this case, the CPT Code Manual definition of codes 31615, 31502 are tracheobronchoscopy through established tracheostomy incision, and a tracheotomy tube change. 

We find that CPT code 31615, 31502 is not supported in the medical record. Specifically, no documentation was provided to support these procedures. Additional documentation was requested by the plan and it was not received. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met.

Therefore, we decided that the Plan does not have to pay for inpatient services (31615, 31502) provided November 17, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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. The enrollee was admitted for a stroke and hypertension. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided January 13, 2021.

You asked the Plan to pay for the continuous glucose monitor. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain valid medical records which support medical necessity for the supplies provided in this case. The records do not document any discussion with the treating physician about the need for this equipment. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter supplies (A4314, A4357) provided April 1, 2021.
You asked the Plan to pay for the catheter supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 A4314, & A4357 are not supported in the medical record. Specifically, place of service 31, inpatient Skilled Nursing Facility (SNF) was submitted on the claim. The records show there was not a covered Part A inpatient SNF stay. Based on this information, we decided that Medicare rules for coverage of the catheter supplies have not been met. Therefore, we decided that the Plan does not have to pay for catheter supplies (A4314, A4357) provided April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) on tooth #11 provided on December 9, 2020.
You asked the Plan to pay for the crown. You say that you need this crown approved for coverage. The Plan denied your request. The Plan says the submitted x-rays do not show any pathological or other damage to the existing crown on tooth #11, nor was any documentation submitted indicating the medical necessity for the replacement of the existing crown.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the crown on tooth #11 was not medically reasonable and necessary. Our physician reviewer found the provided x-rays show that there is no recurrent decay around the crown on tooth #11. The supplied documentation included a statement from the provider that there was no particular issue with the crown, but the member was unhappy with its appearance. Our reviewer found that it is specifically noted in this case that the only reason the crown was to be replaced was that the color was too dissimilar to the surrounding teeth. Under the Plan provisions, a crown may be deemed necessary where there is significant breakdown of the structure, and in this case only if the existing crown was non-serviceable for some reason. Our physician reviewer also found that given the documentation, the only reason for replacement was for a cosmetic color change, and as such would not be considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pay for the crown (D2750) on tooth #11 provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the eye exams provided on May 4, 2021, May 6, 2021 and May 14, 2021.

You asked the Plan to reduce the copayment for the eye exams. You say that your eye became infected and you had to return for three visits. You say that these were billed as an eye exam in error and you should only be responsible for the standard $20 specialist copayment. The Plan denied your request. The Plan says the copayments applied 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 Medicare-covered vision services.

You have been asked to pay a $50 copayment each eye exam. The total amount you owe is $150 ($50/exam x 3 exams = $150). The eye exams fall within the "Vision care" benefit category. The records show three medical eye exams were billed. 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 reduce the copayment for the eye exams provided on May 4, 2021, May 6, 2021 and May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the procedure.

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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301, 81311, 81317, 81321) provided February 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301, 81311, 81317, 81321) provided February 2, 2021.