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

We decided that the Plan does not have to pay for the laboratory testing provided on June 30, 2020.
You asked the Plan to pay for the laboratory testing. You say that the claim for respiratory Covid-19 testing has been denied as out of network. You say that you have no knowledge of the enrollee's coverage prior the specimen's arrival at the laboratory. You also say that you should not be penalized for being out of network as they continue to do their part in providing timely testing and results to the Covid-19 pandemic. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 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.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID pneumonia and was intubated on March 26, 2021. She 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 she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: 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 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 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 enrollee was admitted to the current acute care hospital with sepsis due to an advanced sacral pressure ulcer. The enrollee's vitals are recently stable. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The documentation does not support that the enrollee requires services at the LTACH that are not available at the health care setting being offered by the health plan. 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: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (88305, 88307 and 88342) provided on April 2, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available.
The Plan follows Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. We asked our coder 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 laboratory services. Our reviewer says that CPT codes 88305, 88307 and 88342 meet criteria for billing and reimbursement consideration. Our reviewer found as there is no code for Malignant neoplasm of unspecified site of bilateral female breasts, the coding was appropriate in this case. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have been met. Therefore, we decided that the Plan has to pay for laboratory services (88305, 88307 and 88342) provided on April 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET imaging; skull base to mid-thigh (CPT code 78812-26) provided on June 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the PET scan. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.
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 PET imaging; skull base to mid-thigh (CPT code 78812-26) provided on June 16, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from September 1, 2020, through October 31, 2020, by an out of country non-Plan provider.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says they made multiple, unsuccessful, requests to obtain necessary medical records to make a benefit determination. The Plan states the required information was not received.
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. Medical records were not provided to verify medical necessity. 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 SNF care provided to the enrollee from September 1, 2020, through October 31, 2020, by an out of country non-Plan provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kyphoplasty  surgery for the enrollee.You asked the Plan to pre-approve Kyphoplasty surgery for the enrollee. You say that this surgery is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of surgery. 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 Kyphoplasty surgery for the enrollee. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the imaging studies show a chronic not acute T12 compression fracture. Criteria for kyphoplasty are not met. The fracture is more than 6 weeks old.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kyphoplasty surgery for the enrollee have not been met.Therefore, we decided that the Plan does not have to pre-approve Kyphoplasty  surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 16, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 14, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite on tooth #21 provided on December 7, 2020. You asked the Plan to pay for the resin-based composite. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered because tooth #21 is a posterior tooth that is 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, resin-based composite restorations are only covered in anterior teeth and the buccal surface of posterior teeth, up to the first permanent molars. Tooth #21 is a posterior tooth, and this service is not covered for posterior teeth. Therefore, we decided that the Plan does not have to pay for the resin-based composite on tooth #21 provided on December 7, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 29, 2021 after multiple falls and the family stating they were unable to care for her. There are no documented skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve the inpatient psychiatric care. You say that the enrollee has Alzheimer's disease, and the current provider has been unable to find a memory care center for transition to a lower level of care. You say that further inpatient care is needed while they look for suitable placement. The Plan denied your request. The Plan says the enrollee is considered stable and continued treatment would be considered custodial. The Plan says that a continued inpatient psychiatric stay is not medically necessary.
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 the inpatient psychiatric care. Our reviewer says that the criteria for coverage of inpatient psychiatric services have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on March 16, 2021 with Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment.
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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient rehabilitation on April 21, 2017. You asked the Plan to waive the coinsurance for the inpatient rehabilitation. You say that you had met your maximum out-of-pocket amount. You say you believe that your member responsibility for this claim should be $0.00. The Plan denied your request. The Plan says the claim was reprocessed and 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). Your contract with the Plan clearly says that you must pay 4% of the cost for in-network Medicare-covered services for an unlimited number of days for an inpatient hospital stay. You have been asked to pay $582.38 which is less than the standard 4% of the allowed amount for the inpatient rehabilitation. The allowed amount is $16,002. ($16,002 x 4% = $640.08). The record shows you met your maximum out-of-pocket amount with the $582.38 amount. The inpatient rehabilitation falls within the "Inpatient hospital care" 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 coinsurance for the inpatient rehabilitation provided on April 21, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital care and the emergency room visit provided from October 7, 2020, through October 10, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $279 copayment per day, for days 1-7 for inpatient hospital care and a $90 copayment for emergency room services rendered by an in-network provider. You have been asked to pay $937 ($279 copayment x 3 days=$837) for the inpatient hospital care and a $90 copayment for the emergency room visit provided by an in-network hospital. 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 the inpatient hospital care and the emergency room visit provided from October 7, 2020, through October 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture provided on October 28, 2020. You asked the Plan to pay for the dental item. You say that you were not aware that the provider was out of network. You also say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services and items that you receive out of network 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, dental services and items that you receive out of network are not covered. The record shows that the Plan confirmed that the provider's network status changed to out of network as of September 1, 2020, prior to the date of service in this case. Additionally, the record shows that even if the provider was in network, the partial lower denture is not listed as a covered service.Therefore, we decided that the Plan does not have to pay for the lower partial denture provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery capsular plication and treatment for pincer lesion for the enrollee.
You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was treated for femoroacetabular impingement. He presented with persistent right hip pain. Exam of the right hip reveals range of motion of flexion 110 (left is 120) and decreased internal and external range compared to left. Labral, impingement, and subspinous testing are all positive. There is tenderness to palpation of the gluteus medius and SI joint. Strength is 4/5 in abduction and external rotation. MRI documented bilateral femoroacetabular chondrosis with degenerative labral tearing; mild bilateral gluteal insertional tendinopathy with peritrochanteric edema. However, there is limited published peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is limited documented evidence of a pincer lesion.There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this overall request as an exception. Therefore, this request is 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery capsular plication and treatment for pincer lesion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day Reader Device.You asked the Plan to pre-approve a FreeStyle Libre 14-day Reader Device. You say that the item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14-day Reader Device have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day Reader Device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 11, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. 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 June 11, 2020. 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 June 11, 2020.