Persius/hicric huggingface dataset:
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 IRF admission is necessary.The Plan denied your request. The Plan says you could receive treatment in an alternate level of care.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at an alternate level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at an alternate 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72110), x-ray exam of the cervical spine (72040), and the office visit (99212) provided on February 6, 2020. You asked the Plan to pay for these services. You say that the services provided to you were medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72110), x-ray exam of the cervical spine (72040), and the office visit (99212) provided on February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency wheelchair van transportation services
provided November 25, 2019 to January 13, 2019.
You asked the Plan to pay for the wheelchair transportation services. You say that you were not told that this
service would require an authorization before having the service. You were under the assumption that this
would be covered and you would receive reimbursement. 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 wheelchair van transport
services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for the non-emergency wheelchair van transportation services provided
November 25, 2019 to January 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on January 29, 2020.You asked the Plan to waive the copayment for a spinal canal injection. You say that you were not admitted inpatient and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for surgery services provided in an outpatient hospital facility. You have been asked to pay a $450 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a spinal canal injection provided on January 29, 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 the IRF services are medically necessary. The Plan denied your request. The Plan says you could receive care in another setting.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 3, 2019 through November 14, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this infusion code is not a durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says S codes are not payable by Medicare.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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 3, 2019 through November 14, 2019.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.
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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve9 Skilled Nursing visits.You asked the Plan to pre-approvethe 9 Skilled Nursing visits. You say that you would like reconsideration because these services are medically necessary.The Plan denied your request. The Plan says the records do not show that the member has a medical need for a skilled nurse.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 9 Skilled Nursing visits. Our reviewer says that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the member's condition, or to establish/perform a maintenance program to maintain the member's condition and/or prevent deterioration. Our physician reviewer found the requested Skilled Nursing home health visits are not medically 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 the 9 Skilled Nursing visits have not been met.Therefore,we decided that the Plan does not have to pre-approve9 Skilled Nursing visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says additional therapy is needed to get to the previous level of function and to succeed at home.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on January 29, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $40 copayment for each specialist visit. Review of the file shows that you had a specialist office visit on January 29, 2020. You have been asked to pay a $40 copayment for the visit. The visit falls within specialist 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 the office visit you had on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 2, 2020. You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim. The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the wrist hand orthoses, and the knee orthosis and suspension sleeve provided on February 17, 2020.You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the wrist hand orthoses (L3916), and the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this claim.The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records, around the date of the order, supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650), the wrist hand orthoses (L3916), and the knee orthosis (L1833) and suspension sleeve (L2397) have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, the wrist hand orthoses, and the knee orthosis and suspension sleeve provided on February 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused detailed and extensive oral evaluation, 2D oral/facial photographic image, diagnostic casts, and supplies and materials provided from August 30, 2019 to October 28, 2019.You asked the Plan to pay for the problem focused detailed and extensive oral evaluation, 2D oral/facial photographic image, diagnostic casts, and supplies and materials. You say that you had an urgent operation on your jaw on August 30, 2019. You say that these services were medically necessary under your medical plan.The Plan denied your request. The Plan says your plan does not cover these services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the problem focused detailed and extensive oral evaluation, 2D oral/facial photographic image, diagnostic casts, and supplies and materials provided from August 30, 2019 to October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to theenrollee on January 6, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe denied codes remain not supported.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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479HCPCS G0482:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed 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 services. Our reviewer says that the services at issue in this case werenot coded correctly. Our physician reviewer found no provider records or test results have been submitted for review. Therefore, there is no evidence to support that the ordered service was medically necessary, reasonable or provided.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 Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 12, 2019.
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 screening tests are 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 October 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveskilled nursing (SN) visits to be provided in the home health setting.You asked the Planto pre-approvethe requested home health services. You say that it is felt that the enrollee would benefit from home health services.The Plandenied your request. The Plansaysthe enrollee does not require SN visits in the home in order to maintain his condition. The requested care is not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 requested home health services. Our reviewer says that the documentation does not support the medical necessity of the requested home health services. Our physician reviewer found the enrollee is a 77 year old female with a past medical history of chronic obstructive pulmonary disease and type II diabetes. There is no documentation that shows that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The provided records do not document any acute or chronic unstable conditions that require skilled nursing 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 requested home health services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveskilled nursing (SN) visits to be provided in the home health setting.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the knee.You asked the Plan to pre-approve an MRI of the knee. You say that the requested MRI of the knee is medically necessary.The Plan denied your request. The Plan says the requested MRI of the knee is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the knee. Our reviewer says that the requested MRI of the knee is not medically necessary. Our physician reviewer found this enrollee presents with a 2-month history of right knee pain. Current exam documented positive lateral joint line tenderness and positive lateral McMurray's test. X-rays of the right knee showed adequate joint space. Under consideration is a request for MRI of the knee. Current evidence based medical guidelines and literature would not support this request prior to documented failure of conservative treatment trial. There is no history of trauma. There is no clear documentation of functional limitations. A corticosteroid injection was performed at the time of evaluation with no documentation of response to this injection. There is no evidence of any other conservative management, including over-the-counter medications, activity modification, or exercise. There is also no clear documentation of mechanical symptoms and no clinical evidence of effusion. Therefore, this request for MRI of the knee would not be considered medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the knee have not been met.Therefore, we decided that the Plan does not have to pre-approve an MRI of the knee.