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 care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have 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 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 the patient was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient 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 have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the photophoresis rendered on January 16, 2021.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that extracorporeal photopheresis for the treatment of
bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when extracorporeal
photopheresis is provided under a clinical research study.
We looked at the file and Medicare rules. The file shows that the services were not provided as part of a
clinical research study. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the photophoresis
rendered on January 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999).

You asked the Plan to pay for an unspecified adjunctive procedure. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an unspecified adjunctive procedure have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650), provided on February 24, 2021.

You asked the Plan to pay for a back brace. You say that the item is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered only when ordered for certain indications. 

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 back brace. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a physical examination of the back, nor is there documented need for a lumbar-sacral orthosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a back brace have not been met. Specifically, there was insufficient documentation indicating the medical necessity of the requested item. Therefore, we decided that the Plan does not have to pay for a back brace (L0650), provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) coded 93042 provided on September 4, 2020.
You asked the Plan to pay for the rhythm ECG. 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 separately payable.
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, we have confirmed that code 93042 for the rhythm ECG has a bundled relationship with code 31500 (Intubation, endotracheal, emergency procedure) and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) coded 93042 provided on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image
(D0230 x2) received March 3, 2021.
You asked the Plan to pay for the intraoral periapical additional radiographic images. You say that the x-rays
were unnecessary and therefore you should not have to pay for them. The Plan denied your request. The Plan
says you have exceeded the frequency limitation for this 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 service is only covered
under this benefit for one procedure per calendar year. Your provider billed for three intraoral radiographic
image procedures on this date of service. The Plan agreed to cover the first procedure (D0220). The remaining
two procedures (D0230 x2) exceed the benefit limitation and are your responsibility for payment. Therefore,
we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image
(D0230 x2) received March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on March 2, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are not
medically necessary.
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. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that PCR amplification techniques raise considerable concerns regarding contamination from one
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally,
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large
groups of patients for many of the microorganisms.
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 have not been met. Therefore, we decided that the Plan does not have
to pay for the urine PCR testing provided on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services (CPT 60390, 63091) provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes are not supported in the medical records submitted.
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 63090:
partial or complete vertebral corpectomy (vertebral body resection), using a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, orsacral; for a single segment (listed separately in addition to code for primary procedure) CPT 63091: partial or complete vertebral corpectomy (vertebral body resection), using a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; for each additional segment (listed separately in addition to code for primary procedure) 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the operative report does not include enough information to confirm that the criteria has been met for the services billed, and therefore would not be covered. 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 orthopedic services (CPT 60390, 63091) provided to the enrollee on October 22, 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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found you were admitted to the hospital with a knee infection and congestive heart failure. You are now medically stable with 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.

You may benefit from further therapy but do not require an intensive therapy program in an IRF. 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. 

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: 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program. Medically necessary services 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.
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 waive the copayments for the urgent care visits provided on February 25, 2021 and February 26, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each Medicare-covered urgently needed care visit at a preferred facility. You have been asked to pay $60 ($30 copayment x 2) for the urgent care visits provided. 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 urgent care visits provided on
February 25, 2021 and February 26, 202
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a dual-energy x-ray absorptiometry (DXA) bone density scan (77080) provided on February 18, 2021.
You asked the Plan to waive the copayment for a DXA bone density scan. You say that you had this scan as a routine periodic test and normally the service is covered with no copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that you will only pay one copayment per day even if multiple x-rays are performed.
You have been asked to pay a $10 copayment for a DXA bone density scan. The EOC confirms $10 is the required copayment for this service. The records show that you had several x-rays done on this date of service and only one copayment was assessed. A DXA bone density 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 a dual-energy x-ray absorptiometry (DXA) bone density scan (77080) provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 9, 2020.
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 9, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for a low dose CT scan of thorax for a lung cancer screening provided on March 15, 2021.
You asked the Plan to waive the copayment for a low dose CT scan of thorax for a lung cancer screening. You say that you have never been charged in the past and were sent a letter stating you would not owe anything for the service. The Plan denied your request. The Plan says that 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. Your contract with the Plan says there are no cost-sharing charges for screenings for lung cancer with low dose computed tomography. The Plan says you must pay a $150 copayment for a low dose CT scan of thorax for a lung cancer screening. Based on the Plan contract, however, you cannot be asked to pay for a low dose CT scan of thorax for a lung cancer screening. The Plan did not provide any documentation that you exhausted this benefit nor that the screening was ordered for diagnostic purposes. Therefore, we decided that the Plan has to waive the copayment for a low dose CT scan of thorax for a lung cancer screening provided on March 15, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fundus photography with interpretation and report (92250) provided March 3, 2021.
You asked the Plan to pay for retinal imaging. You say that you need retinal imaging because dilation is not safe. The Plan denied your request. The Plan says this service is not included in your routine vision benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers routine vision benefits in excess of Medicare coverage, retinal imaging is not among those services covered. Therefore, we decided that the Plan does not have to pay for fundus photography with interpretation and report (92250) provided March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 30, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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.

Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general cardiac risk stratification and would not be considered medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 30, 2020.