Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab tests provided on November 20, 2020.

You asked the Plan to waive the copayment for lab tests. You say that this was preventative blood work and you should not owe a copayment. 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 $10 copayment for lab tests. 

You have been asked to pay a $10 copayment for lab tests. Lab tests fall 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 copayment for lab tests provided on November 20, 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 admission 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 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 was admitted to acute care inpatient hospital on for COVID-19 pneumonia. The enrollee required oxygen supplementation for one day. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for myocardial perfusion imaging and a stress test and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 4, 2020.

You asked the Plan to waive the copayments for myocardial perfusion imaging and a stress test and to waive the coinsurance for a Medicare Part B drug injection. You say that you were not aware that you would owe such a high copayment. 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 $250 copayment for diagnostic radiology and a $60 copayment for diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received myocardial perfusion imaging on August 4, 2020. Therefore, you are responsible to pay the $250 copayment. You received a stress test on August 4, 2020. Therefore, you are responsible to pay the $60 copayment. 

You received a Medicare Part B drug on August 4, 2020. The allowed amount is $236.72 and 20% of that is $47.34. 

The total amount you owe is: $357.34.

You have been asked to pay the total amount of $357.34 for myocardial perfusion imaging, a stress test and a Medicare Part B drug injection. Myocardial perfusion imaging and a stress test fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 myocardial perfusion imaging and a stress test and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a pelvic ring fracture (27217 and 27216) provided on August 22, 2020.

You asked the Plan to pay for the treatment of a pelvic ring fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 27216 and 27217 have a status indicator of I and are not valid for Medicare purposes.

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 27217 and 27216 are not supported in the medical record. Specifically, per the Physician Fee Schedule, CPT codes 27216 and 27217 have a status indicator of I. This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the treatment of a pelvic ring fracture have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of a pelvic ring fracture (27217 and 27216) provided on August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus and diphtheria toxoids injection into muscle (CPT code 90471) and immunization administration (CPT Code 90471) on October 22, 2020.

You asked the Plan to pay for the immunizations. You say that you did not ask for the vaccine, rather your doctor told you that you needed it because you were overdo for it. The Plan denied your request. The Plan says the immunizations are not covered by Medicare Part B. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunizations. Tetanus and diphtheria toxoids injection into muscle (90714) and immunization administration (90471) are not listed as covered Medicare Part B services that your plan covers. Therefore, we decided that the Plan does not have to pay for tetanus and diphtheria toxoids injection into muscle (CPT code 90471) and immunization administration (CPT Code 90471) on October 22, 2020.

Benefits for the immunizations 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial gastrectomy and inpatient hospital care for the enrollee.

You asked the Plan to pay for these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that a partial gastrectomy is not indicated as standard treatment for gastroparesis and the associated Inpatient admission is denied due to the related surgical procedure being denied.

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 these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee. The member has been experiencing reflux and regurgitation of food. The enrollee has had abdominal pain and discomfort associated with nausea and change in bowel habits. A partial gastrectomy is not indicated as standard treatment for gastroparesis. There are non-surgical treatments for gastroparesis including endoscopic treatments that may be less risky and with less morbidity. The clinical value and effectiveness of a partial gastrectomy in the setting of gastroparesis have not been demonstrated in the peer-reviewed literature. A novel technique of partial longitudinal gastrectomy without anastomosis has been proposed as a treatment for patients with gastroparesis. Beyond the improvement in gastric emptying, hormonal changes from the removal of the gastric fundus may make diabetic control easier. The record does not show that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. 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 a partial gastrectomy and inpatient hospital care for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing needs and the enrollee is not participating in therapy services at this time and the enrollee's functional abilities have plateaued.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from May 31, 2020, to June 1, 2020.

You asked the Plan to pay for the inpatient hospital services. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says all inpatient care provided after 10:00 am on May 31, 2020 was not needed on an emergent basis.

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 review indicates that by 10:00 a.m. on 5/31/2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility. Our physician reviewer found post-stabilization care services after 10:00a.m. on 5/31/2020 were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient 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 for inpatient hospital services provided from May 31, 2020, to June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L2397, L1833) provided September 19, 2020.

You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the provider ever saw the member for an examination.

The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 

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 knee orthoses and suspension sleeves. Our reviewer says that the services were not medically necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L2397, L1833) provided September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) and the consultation (D9310) provided on October 21, 2020.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says 2D oral or facial photographic image is not listed as a covered service. The Plan says consultation is not listed as a covered service either.

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 2D oral or facial photographic image (D0350) and the consultation (D9310) provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the UroVysion FISH (88121) provided on September 30, 2020.

You asked the Plan to pay for the UroVysion FISH. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not cover this as a screening test for the member's diagnosis.

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 pay for the UroVysion FISH. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found UroVysion FISH is considered experimental/investigational as a screening test for urothelial cancer. 

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 UroVysion FISH have not been met. Therefore, we decided that the Plan does not have to pay for the UroVysion FISH (88121) provided on September 30, 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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided already in the current acute care setting already approved.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair you received on October 9, 2020.

You asked the Plan to pay for the crown repair. The Plan denied your request. The Plan says this 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 services are not among those covered under this benefit. The Plan covers only those dental codes listed in the Evidence of Coverage. Dental code D2980 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the crown repair you received on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment
supported porcelain/ceramic crown (D6058) provided on September 29, 2020.

You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that
these services were necessary. The Plan denied your request. The Plan says these services are not 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
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on
September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on May 23, 2020 to May 29, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on May 23, 2020 to May 29, 2020.

Benefits for these services 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: 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 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 you required minimal assistance times two to walk 25 feet with a front wheeled walker. You required minimal assistance with bed mobility and toileting. You required moderate assistance with transfers. The documentation does not support that you require 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. Your care needs can be met at a lower level of 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.