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

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on August 27, 2020.You asked the Plan to waive the copayment fora colonoscopy. You say that this should be considered a screening and not diagnostic.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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received a diagnostic colonoscopy on August 27, 2020, due to a personal history of colon cancer. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy 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 fora colonoscopy provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis provided on December 20, 2019.You asked the Plan to pay forknee orthosis. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this item is correct, because the documentation submitted did not include a valid order for this item.The Plan must followMedicare rules. Medicare rules say that a detailed written order is required to justify payment for a knee orthosis L1833. We looked at the file and Medicare rules. The documentation submitted does not include a detailed written order for this item. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora knee orthosis provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are 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. 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 documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit and related services provided on July 14, 2020.
You asked the Plan to pay for the emergency department visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were not billed in accordance with CMS guidelines.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the plan is denying this claim due to the claim not being billed in accordance with CMS guidelines. However, no information was provided on what exactly was not billed correctly per CMS guidelines. Since this information was not provided, the plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the emergency department visit and related services provided on July 14, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9328
provided from June 4, 2020, to July 9, 2020.
You asked the Plan to pay for CPT code S9328. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have
to pay for the home infusion therapy services with CPT code S9328 provided from June 4, 2020, to July 9,
2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have topay forthe anesthesia services provided on March 24, 2020.You asked the Plan to pay forthe anesthesia services. You say that the claim was initially filed to hospice. You say that the claim was denied because the enrollee was in the hospital on the date of service and not on hospice.The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on March 21, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe anesthesia services provided on March 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral - periapical each additional radiographic image (X-Ray) (D0230) provided on August 10, 2020.
You asked the Plan to pay for a comprehensive oral evaluation and an intraoral - periapical X-Ray. You say that the services should be covered. The Plan denied your request. The Plan says you have exhausted the maximum benefit allowed.
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. This benefit includes a comprehensive oral exam once every three years and an intra-oral X-Ray once every calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the records indicated you have already exhausted these benefits for the Plan year. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral - periapical each additional radiographic image (X-Ray) (D0230) provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pay forthe observation discharge services billed for date of service March 27, 2020 with CPT code 99217.You asked the Plan to pay forthe billed observation discharge care. You say that these services were furnished in good faith and should be reimbursed due to medical necessity.The Plan denied your request. The Plan says the documentation does not support that the enrollee was in observation status at the time of discharge from the facility. The inpatient Place of Service code and inpatient discharge service code should be used for this date.The Plan must follow Medicare rules. Medicare rules say thatproviders must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).We find that CPT code 99217 is not supported in the medical record. Specifically, the documentation shows that the enrollee was under observation starting on March 24, 2020 and admitted to inpatient status on March 26, 2020. As such, this discharge code for outpatient care is not appropriate. Based on this information, we decided that Medicare rules for coverage of the billed observation discharge care have not been met.Therefore, we decided that the Plan does not have to pay forthe observation discharge services billed for date of service March 27, 2020 with CPT code 99217.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvea thigh lift.You asked the Planto pre-approvethe lift. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no documentation of a failure at conservative therapy.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the lift. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you complain of pain, chronic rashes and irritation from pooling urine directly associate to the skin to skin contact of your excess soft tissue of the medial thighs. Generally, medial thigh lifts are considered cosmetic surgical treatments; however, in this case, the medical documentation supports that this is not cosmetic treatment but reconstructive treatment of a functional impairment. Conservative management may improve chronic rashes temporarily, but would not likely correct the pain and urine irritation present.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 lift have been met.Therefore, we decided that the Planhas to pre-approvea thigh lift.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on May 6, 2020 by an OON
provider. You asked the Plan to pay for the prophylaxis. You say that a Plan representative gave you 3 in-network
dentists, but when you called them you were told that they were no longer part of your Plan's network. The
Plan denied your request. The Plan says this service was rendered by a non-participating dentist. The Plan also
says that you must use network providers to receive dental services.
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
prophylaxis provided on May 6, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that this is medically necessary.The Plandenied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
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 services are 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. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that a bath chair is medically necessary.The Plandenied your request. The Plan says bath and shower chairs are not covered.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care (99308) provided on June 10, 2020.You asked the Plan to pay fornursing facility care. You say that you are appealing with medical records to process the claim for payment.The Plan denied your request. The Plan says rules for payment have not been met.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 dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay fornursing facility care (99308) provided on June 10, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten PT visits.
You asked the Plan to pre-approve an additional ten PT visits. The Plan denied your request. The Plan says
physical therapy for lymphedema is considered medically necessary when the enrollee needs the skills of a
physical therapist. Based on the clinical information provided, the enrollee had a worsening of shoulder
movement. There were no changes in size of the arm due to not following the treatment program outlined by
the therapist. The notes do not show that the enrollee needs the ongoing skills of a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 an additional ten PT visits. Our
reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is
not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior
therapy for this condition and it does not appear that the enrollee requires the unique skills of a professional
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in an independent
exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an additional ten PT visits have not been met. Therefore, we decided that the Plan does not have to
pre-approve an additional ten PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physician services provided on September 15, 2020.You asked the Plan to waive the copayment forthe physician services. You say that you should not be charged because this visit was after a procedure.The Plan denied your request. The Plan says the procedures you had do not have a global follow up period.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 $20 copayment for physician services. You have been asked to pay a $20 copayment for the physician services. The physician services fallwithin the physician 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 forthe physician services provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an implant
supported crown (D6065).
You asked the Plan to pre-approve the dental services. You say that these services were for a crown over a
previous implant. You say that the implant was done by another firm and paid in full. You also say that the
comprehensive dental benefit includes crowns and therefore these services should be at least partially paid. The
Plan denied your request. The Plan says prefabricated abutment is not listed as a covered service. The Plan says
that implant supported crown is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The Evidence of Coverage clearly states that any service not listed are
not covered. Therefore, we decided that the Plan does not have to pre-approve a prefabricated abutment
(D6056) and an implant supported crown (D6065).