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

We decided that the Plan does not have to pre-approve insertion of an Vertiflex Superion interspinous process stabilization device (Current Procedural Terminology (CPT) code 22869), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an Vertiflex Superion interspinous process stabilization device (Current Procedural Terminology (CPT) code 22869), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 7, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you had no choice for a freestanding facility so you should be reimbursed the extra $70. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for advanced imaging services at an in-network outpatient hospital. You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 copayment for the CT scan provided on December 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile imaging services provided on June 5, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the mobile imaging services provided on June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 the member has not had a change in function warranting daily skilled therapy.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a dietician.

You asked the Plan to waive the copayment for the telehealth visit. You say that you talked to the dietician but they haven't sent you or your doctor a formal diet plan yet. Based on this, you do not believe you should have to pay a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits including telehealth services.

You have been asked to pay a $35 copayment for the telehealth visit. 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 the telehealth visit you had with a dietician.

Your complaint about not yet receiving a diet plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available.
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 vision services provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the routine exam, the X-ray, the bitewing X-ray, or pay for the prophylaxis.

You asked the Plan to pay for the dental services. You say that you require additional cleanings per year. The Plan denied your request. The Plan says you are responsible for the difference between the Maximum Allowable Charge for covered services received out of network, and you have a limit of two prophylaxis services per calendar year.

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 exceed those covered under this benefit. The Plan has agreed to pay 100% of the Maximum Allowable Charge (MAC) for the routine exam, X-ray, and bitewing X-ray, and you are responsible for the difference in cost between what the provider charged and the MAC. The Plan allows two prophylaxis (cleaning) services per calendar year. The Plan has provided evidence that you received two cleanings earlier in the year. Therefore, we decided that the Plan does not have to pay an additional amount for the routine exam, the X-ray, the bitewing X-ray, or pay for the prophylaxis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (14061, 15574, 15576) provided on August 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 14061 is "Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm". The CPT Code Manual definition of code 15574 is "Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet". The CPT Code Manual definition of code 15576 is "Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral". We asked our coding 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 services. Our reviewer says that the use of CPT codes 14061, 15574, and 15576 is not supported by the records provided. Our coding reviewer found that CPT code 14061 is an adjacent tissue transfer is also known as rearrangement procedure is medical procedure wherein flat sections of health skin and other tissues are transferred or transplanted to the area adjacent to skin defect. This procedure was not documented in the operative report. For CPT codes 15574 and CPT 15576, a tubed pedicle flap is made by elevating a long strip of tissue from its bed. The cut edges are then sutured together to form a tube. This procedure was also not documented in the operative report. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (14061, 15574, 15576) provided on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that 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 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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that you do not require the intensity of services provided at an IRF. Specifically, you
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for falls and readmission to acute care. The Plan denied your request. The Plan says the enrollee is unable to tolerate 3 hours of therapy per day.
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 physician reviewer found that the enrollee was treated for a fractured wrist after a fall and is living at home. She has had decline in function. Her medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction and surgical extraction provided on
November 19, 2020.
You asked the Plan to pay for the extractions. You say that you assumed these services would be covered. The
Plan denied your request. The Plan says the calendar year maximum has been reached.
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 Plan offers a $1,500 combined
allowance for supplemental preventive and comprehensive services every year. The contract clearly says that
you are responsible for any amount over and above the allowance amount. The record shows that you met the
annual maximum benefit while processing this claim for the November 19, 2020, date of service and your
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
simple extraction and surgical extraction provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not urgent, emergent or 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 the laboratory services provided on November 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 23, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 14, 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 need acute rehabilitation in order to return to your previous lifestyle. The Plan denied your request. The Plan says that your records show that your care is not complex and you do not need a team of providers.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis and had a left below the knee amputation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.