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

We decided that the Plan does not have to pay for the laboratory services provided from May 1, 2019 to June 26, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the documentation submitted did not support that the provider did performed the services billed. The documentation does not support that the enrollee was a patient of the billing provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided from May 1, 2019 to June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the acupuncture visits provided from December 19, 2019 to March 4, 2020.
You asked the Plan to waive the copayments for the acupuncture visits. You say that you should not have been charged the copayments. The Plan denied your request. The Plan says the claims for December 2019 were reprocessed with the correct copayment of $10 and the claims for 2020 have been processed with 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 a $10 copayment per primary care visit in 2019, depending upon the plan in which you are enrolled and a $5 copayment per primary care visit in 2020, depending upon the plan in which you are enrolled. You have been asked to pay a $10 copayment for each acupuncture visit in 2019 and a $5 copayment for the acupuncture visits in 2020. The acupuncture visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 the acupuncture visits provided from December 19, 2019 to March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2017 to July 13, 2017.
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was warranted. The Plan denied your request. The Plan says that that the member had no fever, altered mental state and was hemodynamic instability.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2017 to July 13, 2017.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services you need in other settings.
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. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly contact guard assist assist-to-modified independent for functional transfers and ADL's and a less intensive, longer duration of therapy (home health or SNF) can address current needs. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diovan HCT.
You asked the Plan to pre-approve Diovan HCT. You say that this has been the only medication to regulate the enrollee's blood pressures. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Diovan HCT.
Benefits for Diovan HCT 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 15, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on December 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation does not show medical necessity or rationale for the testing.
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 testing services. Our physician reviewer found that the enrollee presented with sore throat, cough, congestion and chills. Her vital signs were stable. The records do not show that at the time of service, the provided testing was medically necessary to treat the enrollee's condition. The enrollee was treated empirically with azithromycin and an albuterol inhaler for a mild upper respiratory infection. The respiratory DNA/RNA panel performed did not appear to add any useful information to the treatment of the enrollee's condition. 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve hydrocodone-acetaminophen tablets.
Benefits for 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair, accessories, power seating system tilt, and elevating leg rests.
You asked the Plan to pre-approve a Group 2 power wheelchair, accessories, power seating system tilt, and elevating leg rests. You say that you need the a Group 2 power wheelchair, accessories, power seating system tilt, and elevating leg rests. The Plan denied your request. The Plan says there is no evidence in the notes that the enrollee requires power tilt to manage increased tone or spasticity or the presence of lower extremity edema for the elevating leg rests.
The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The record does not show medical necessity for the power seating system tilt and elevating leg rests. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair, accessories, power seating system tilt, and elevating leg rests.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from December 13, 2019 to February 27, 2020.
You asked the Plan to pay for home health care. You say that these services were home health aide services that meet the Medicare criteria for coverage. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the services were custodial in nature and thus not covered by Medicare.
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 home health care. Our reviewer says that the home health services provided do not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee did not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not have complex wound care, new enteral feedings, a new tracheostomy, or other skilled nursing need. The enrollee's needs were not at a skilled nursing level of care. The records show that skilled therapy services were not required to effectively provide treatment, care, and/or services which were medically necessary for the enrollee. Without the need for skilled nursing or skilled therapy services, the enrollee does not meet the qualifying criteria for home health care. Home health aide services were not reasonable and necessary to the treatment of the enrollee's illness or injury by skilled professional staff.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health care services provided from December 13, 2019 to February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair.
You asked the Plan to pre-approve a standard wheelchair. You say that the enrollee has severe gait and mobility impairment. The Plan denied your request. The Plan says there is not report of gait with the walker or home assessment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair. We looked at the file and Medicare rules. There is no documentation supporting mobility limitation or home access. Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 16, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because this claim was erroneously denied as inclusive to another procedure. The Plan denied your request. The Plan says that payment is not allowed because this claim contains non-anesthesia services submitted by an anesthesiologist.
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 looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was provided by a provider different than that of the anesthesia procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 13, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composites. You say that this provider was your assigned dentist at the time the service was provided. The Plan denied your request. The Plan says the services were rendered by a non-Plan provider. The Plan also says that unless it has been approved, the Plan only covers services done by your assigned dentist.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on January 13, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided on November 2, 2018 to November 30, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the dialysis services provided out of network. You say that if the enrollee had not received dialysis he would not have been able to sustain life. The Plan denied your request. The Plan says there is no network deficiency for the services in dispute. The Plan says that it was not necessary for the services to be provided out of network.
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 has network providers available who can provide 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 dialysis services provided on November 2, 2018 to November 30, 2018 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D testing with procedure code 82306 provided on February 18, 2020.
You asked the Plan to pay for Vitamin D test. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Vitamin D 25 hydroxy testing with procedure code 82306 is only covered when billed with certain, specific diagnosis codes. We looked at the file and Medicare rules. This test was not billed with a covered diagnosis code. Based on this information, we decided that Medicare rules for coverage of Vitamin D test have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D testing with procedure code 82306 provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that it is hard to breathe while walking and you need oxygen to get to your vehicle for appointments and grocery shopping. The Plan denied your request. The Plan says Medicare covers oxygen equipment for use within the home not for travel or use outside of the home.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. The record shows that you have been approved for a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks would meet your in-home needs and serves the same purpose as a portable oxygen concentrator.
We looked at the file and Medicare rules. You have requested a portable oxygen concentrator for use outside the home. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code G0105 provided on December 4, 2019.
You asked the Plan to pay for CPT code G0105. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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 G0105 is Colorectal cancer screening; colonoscopy on individual at high risk. We find that CPT code G0105 is supported in the medical record. Specifically, the medical records provided document that the enrollee has a history of polyps. A personal history of polyps makes the enrollee at high risk for colorectal cancer per Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of CPT code G0105 have been met. Therefore, we decided that the Plan has to pay for CPT code G0105 provided on December 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillofacial Computed Tomography (CT) scan.
You asked the Plan to pre-approve CT scan. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because it is not necessary to perform this CT scan in addition to the already approved CT scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee does not need 2 separate scans to prepare for surgery. The approved CT scan will provide adequate imaging for preparation. This requested additional scan will not provide any additional information that is necessary to plan for surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillofacial Computed Tomography (CT) scan.