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

We decided that the Plan does not have to pre-approve a referral out-of-network for intravitreal injections of
Avastin and required scans.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary, as there is appropriate care available in-plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral out-of-network for intravitreal injections of Avastin and required scans.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says coverage may be provided through a Medicare Part D (prescription drug) 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 Rhopressa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute coded as E0118.

You asked the Plan to pre-approve the requested crutch substitute. You say that you have been on crutches for four months, and this is difficult for you. The crutches cause you pain and do not allow you to be independent. The requested knee scooter would allow you to be able to care for yourself. The Plan denied your request. The Plan says this is not considered medically necessary.

The Plan must follow Medicare rules. Medicare rules say that crutch substitutes are not covered as there is not sufficient evidence to support the medical necessity of these items. 

Although this may be appropriate for you, Medicare does not currently consider these items reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute coded as E0118.
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 it is medically necessary for the enrollee to receive LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is a 75-year-old female who was admitted to the current acute care hospital with diarrhea. The patient appears to be improving but does not have a stable feeding source, and only requires short-term additional acute care services for additional monitoring and treatment that can be safely received at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when the patient is more stable and treatment has completed.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the unspecified preventive service (D1999) provided on January 26, 2021.

You asked the Plan to pay for the dental services. You say that the unspecified preventive service should be covered. You say that the dentist gave you a resin crown, not a porcelain crown. You also say that you should not owe this much. The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered service. The Plan says that crowns have a 50% coinsurance. The Plan also says that the services on the bill are consistent with the chart notes from the dental office.

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 preventive service is not among those covered under this benefit. Additionally, the chart notes provided by the dental office indicate that the services billed match the services provided. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the unspecified preventive service (D1999) provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on January 26, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 28, 2020, through December 1, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on November 28, 2020 with a complaint of abdominal pain for 1 day. She was evaluated and admitted with left lower quadrant abdominal swelling, mass and lump, malignant neoplasm of pelvis, urinary tract infection, acute kidney failure, infectious gastroenteritis and colitis, essential (primary) hypertension, anemia in other chronic diseases classified elsewhere, unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere, pure hypercholesterolemia, hyperlipidemia, diverticulosis of large intestine without perforation or abscess without bleeding, constipation, hyperglycemia, contact with and (suspected) exposure to other viral communicable diseases, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, long term (current) use of antithrombotic/antiplatelets and long term (current) use of aspirin. She was treated; her condition stabilized and improved, and she was discharged when considered medically stable on December 1, 2020. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 28, 2020, through December 1, 2020.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic laryngoscopy provided by a participating provider on January 22, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that this was a normal doctor visit. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $150 copayment for outpatient surgery/outpatient hospital. 

You have been asked to pay a $150 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/outpatient hospital 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 a diagnostic laryngoscopy provided by a participating provider on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from May 4, 2020, through May 15, 2020, and May 26, 2020, through June 9, 2020.

You asked the Plan to waive the copayment for the inpatient stays. You say that if you were to pay the invoices
the out-of-pocket limit would be $9,205.85, which is not what the contract states. You say that the Plan is
responsible for payments and the invoices should be paid. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment each day for days 1 to 7 for Medicare-covered hospital care and a $0 copayment
for additional Medicare-covered days at an in-network inpatient hospital.

The enrollee has been asked to pay a total of $3,075.29 for the inpatient stays.

The inpatient stays fall within the "Inpatient Hospital Care" benefit category. This means that the enrollee has
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for the inpatient stay provided by Maine Medical Center from May 4, 2020,
through May 15, 2020, and May 26, 2020, through June 9, 2020.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the patient appears more stable and improving but is still requiring additional short-term acute care services that can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered soon when treatment has been completed.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged management and evaluation service provided on February 17, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the prolonged management and evaluation service. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. 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 for the prolonged management and evaluation service provided on February 17, 2021 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 28, 2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on
September 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a psychotherapeutic visit (90837) with an out of network telehealth provider on January 7, 2021.

You asked the Plan to pay for a psychotherapeutic visit. You say that outpatient behavioral health visits are a covered benefit with 30% coinsurance. The Plan denied your request. The Plan says that out of network telehealth visits are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that PPO plans must cover all Medicare-covered services out-of-network but may apply higher cost sharing. Medicare has expanded telehealth coverage to allow all providers who may bill Medicare for professional services to be paid for telehealth services. 

The Plan at issue is a PPO and cannot deny coverage of certain out-of-network services, such as telehealth. The PPO plan is also not allowed to impose prior authorization requirements on covered out-of-network care. As such, we find that the Plan has not provided any valid denial rationale to support non-payment of this claim. Therefore, we decided that the Plan has to pay for a psychotherapeutic visit (90837) with an out of network telehealth provider on January 7, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 24, 2021.

You asked the Plan to pay for the ambulance services. You say that 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 February 24, 2021. 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 provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided on January 13, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation failed to meet the required key components.

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 99223 is initial hospital care, typically 70 minutes are spent at the bedside. We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not indicate the amount of time the physician spent with the enrollee.

Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services provided on January 13, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 12, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network physician. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on January 12, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on January 20, 2021.

You asked the Plan to pay for the dental services. You say that you signed up for the PPO plan, not HMO. You say that you have 3 claims with a $0 payment. You also say that you were not able to submit an email to the Dental Plan with your membership number. The Plan denied your request. The Plan says the provider in this case does not participate with the Dental Plan. The Plan says that dental services must be performed by a participating provider in the Dental Plan's network for your Medicare Advantage plan in order to be 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. 

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 pay for the oral exam (D0120) and prophylaxis (D1110) provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950).

You asked the Plan to pre-approve a core buildup. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 core buildup (D2950).