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

We decided that the Plan does not have to waive the copayments for radiation therapy provided from October 1, 2020, to October 30, 2020.

You asked the Plan to waive the copayments for radiation therapy. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $60 copayment for radiation therapy. 

You received radiation therapy from October 1, 2020, to October 30, 2020, for a total of 20 visits. Therefore, you are responsible to pay a $60 (copayment) x 20 (radiation therapy services) = $1,200. 

You have been asked to pay the total copayment amount of $1,200 for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for radiation therapy provided from October 1, 2020, to October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's complex medical needs
require ongoing acute care. The Plan denied your request. The Plan says the medical records do not establish
medical necessity.

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 physician
reviewer found that the enrollee was admitted to the acute care hospital with respiratory failure. The enrollee is
receiving hemodialysis. It is noted that the enrollee still requires acute care hospitalization. LTACHs are
certified as acute care hospitals, and in general, do not provide clinical services that are materially different
than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care
services have not been denied. The documentation does not support that the enrollee in this case requires
services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
The documentation does not support that an additional 25 days of hospitalization are reasonably expected for
the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable,
and appropriate for the diagnosis and condition of the enrollee at this time.

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on December 4, 2020.

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 testing is not covered.

The Plan must follow Medicare rules. The rules say that tests that include more than 5 viral pathogens are non-covered. 

We looked at the file and Medicare rules. The testing at issue is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on December 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on December 14, 2020.

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. Medicare rules say that inpatient services must be billed with POS code
21.

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the
date of service at issue. The claim was not billed with the required POS code 21. 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 chest x-ray rendered on December 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from December 1, 2020, to December 2, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you are not sure how you were supposed to get these medications on your own when you were in the hospital. You say that these should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

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 for the self-administered drugs provided in an outpatient setting from December 1, 2020, to December 2, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and shunt reprogramming provided by an out-of-network provider on May 7, 2020.

You asked the Plan to pay for the office visit and shunt reprogramming. You say that the claim was denied for authorization in error. You say that the notes show medical necessity, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says a non-network provider referred the member for services and the services were not authorized.

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 items/services at issue in this appeal. 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 office visit and shunt reprogramming provided by an out-of-network provider on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism (E0627) provided September 30,
2020, by a provider not certified with Medicare.

You asked the Plan to pay for the seat lift mechanism. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says payment cannot be made to a provider who
is not certified with Medicare.

The Plan must follow Medicare rules. Medicare rules say that payment can only be made to providers who are
enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to
pay for the seat lift mechanism (E0627) provided September 30, 2020, by a provider not certified with
Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from May 29, 2020, to June 1, 2020.

You asked the Plan to pay for inpatient care. You say that the billed DRG is correct. The Plan denied your
request. The Plan says DRG 074 is supported rather than 073 because diagnosis code G93.41 (Metabolic
encephalopathy) is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 073, cranial and peripheral nerve disorders
with major complication or comorbidity. 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
inpatient care. Our reviewer says that the records do not support the billed DRG. Our physician reviewer found
although the history and physical reported acute metabolic encephalopathy possibly secondary to a
cerebrovascular accident (CVA), the documentation found in the Neurology consult and progress notes did not
confirm the presence of a CVA. Subsequent documentation found in the progress notes included "acute
encephalopathy" and "acute on chronic encephalopathy" among the patient's diagnoses without mention of an
acute systemic, toxic, or metabolic etiology. The progress notes reported the patient as alert and oriented with a
corresponding Glasgow coma score of 14 on the first day of the hospital stay. Per the progress note written on
the day of discharge, the patient remained alert and oriented with a Glasgow coma score of 14. No significant
alteration in cognitive function was reported over the course of the admission that would justify the coding of
encephalopathy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided from May 29, 2020, to June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010 x 2), the provisional crowns (D2799 x 2), the occlusal guard (D9940), the implant supported porcelain crowns (D6065 x 2), the implant supported metal crowns (D6057 x 2) provided from March 16, 2020, to August 13, 2020.

You asked the Plan to pay for the dental services. You say that the amount that was paid was very little. You say that you understand that there are services that apply for payment. You also say that The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that implant related services and the occlusal guard are not listed as covered services. The Plan also says that the benefit for crowns only applies to tooth structure and not for implant supported crowns.

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 surgical placement of implant body (D6010 x 2), the provisional crowns (D2799 x 2), the occlusal guard (D9940), the implant supported porcelain crowns (D6065 x 2), the implant supported metal crowns (D6057 x 2) provided from March 16, 2020, to August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three guided tissue regenerations (D4266 x3), three
surgical placements of implant body: endosteal implants (D6010 x3), two bone grafts at time of implant
placements (D6104 x2), sinus augmentation with bone or bone substitutes (D7951), and consultation (D9310)
provided on October 12, 2020.

You asked the Plan to pay for the guided tissue regenerations, endosteal implants, bone grafts, sinus
augmentation, and consultation. You say that you believe these services should be covered under your medical
insurance. The Plan denied your request. The Plan says the guided tissue regenerations, endosteal implants,
bone grafts, sinus augmentation, and consultation are not covered benefits. The Plan also says that you were
charged correctly for the extraction.

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 guided tissue regeneration
(D4266), surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant
placement (D6104), sinus augmentation with bone or bone substitutes (D7951), and consultation (D9310) are
not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pay for the three guided tissue regenerations (D4266 x3),
three surgical placements of implant body: endosteal implants (D6010 x3), two bone grafts at time of implant
placements (D6104 x2), sinus augmentation with bone or bone substitutes (D7951), and consultation (D9310)
provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 11, 2020.

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. Medicare rules say that claims must be billed with the correct POS code. 

We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed with POS code 12 for home. This POS code is not appropriate for billing of these services. 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 office visit rendered on September 11, 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are 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 you were admitted for surgical repair of a hip fracture after a fall. Your medical
problems are stable. There are no complex nursing or rehabilitation needs. The documentation does not support
that you an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not support that you require an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.

You asked the Plan to pre-approve facet joint injection. You say that you cannot keep going as your pain has
severely affected your ability to function. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because your pain has not been present for at least 3 months and you
have non-facet pathologies that could explain your pain.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered if certain
clinical criteria are 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 facet joint injection. Our reviewer says
that you do not meet the Medicare criteria for the requested facet joint intervention. Our physician reviewer
found you have multiple other pain generators such as a vertebral fracture, disc bulges, and spinal stenosis that
could explain the source of your pain. Therefore, this request is considered not medically reasonable or
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 facet joint injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve a facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring feature/device (A9279) provided November 12, 2020.

You asked the Plan to pay for the monitoring feature/device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a monitoring feature/device (A9279) is not a covered benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitoring feature/device have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring feature/device (A9279) provided November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic vertebroplasty to T8.

You asked the Plan to pre-approve T8 kyphoplasty. You say that the enrollee's disease process falls within the
indications for percutaneous fracture augmentation. The Plan denied your request. The Plan says there is no
documentation of a recent fall and details of injury.

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 T8 kyphoplasty. Our reviewer says that
the request is made after 12 weeks window for vertebroplasty. Our physician reviewer found the request is
deemed not medically reasonable or 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 T8 kyphoplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve thoracic vertebroplasty to T8.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).

You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have headaches at the required frequency.

The Plan must follow Medicare rules. Medicare rules say that coverage of Botox will only be allowed for patients with chronic daily headaches occurring greater than 15 days a month. 

We looked at the file and Medicare rules. The record shows that the enrollee has only 5 or 6 headaches a month. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 power wheelchair and accessories (E0843, E2313, E2377, E2611).

You asked the Plan to pre-approve the group 2 power wheelchair and accessories. You say that this wheelchair is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no documentation to support RESNA certified ATP involvement.

The Plan must follow Medicare rules. Medicare rules say that a group 2 power wheelchair must be provided by a supplier that employs a RESNA-certified ATP. 

We looked at the file and Medicare rules. The documentation submitted does not include proof that the supplier has a RESNA certified employee. Based on this information, we decided that Medicare rules for coverage of the group 2 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 2 power wheelchair and accessories (E0843, E2313, E2377, E2611).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), drugs and medicaments dispensed in the office for home use (D9630), the periodontal scaling and root planing (D4341), and the gingival irrigation, per quadrant (D4921), or provide additional reimbursement for the resin-based composited (D2332).

You asked the Plan to pay for the dental services. You say that the requested services were necessary. The Plan denied your request. The Plan says the requested services are not covered under your plan's supplemental 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.

The Plan originally denied all services as non-covered because the claims processed as though the provider was out-of-network. The provider was in the Plan's network; therefore, the Plan corrected the error and reprocessed the claims, however some services remain denied. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services (D0431, D9630, D4341, D4921) are not among those covered under this benefit. In addition, the Plan agreed to cover the resin-based composite (D2332). You are required to pay a 50% coinsurance for covered fillings (50% of the Plan's allowed amount = $86.50). Based on this information you have been asked to pay the correct amount for the filling. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), drugs and medicaments dispensed in the office for home use (D9630), the periodontal scaling and root planing (D4341), and the gingival irrigation, per quadrant (D4921), or provide additional reimbursement for the resin-based composited (D2332).