Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the safest and most efficient care based on the enrollee's condition and needs. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing care provided from June 1, 2020, to June 30, 2020 by an OON provider.
You asked the Plan to pay for the skilled nursing care. You say that you were not aware of the enrollee's plan, and it was impossible for you to obtain a pre-authorization. You also say that medically necessary care was provided. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.
Medicare rules say that plans can require that authorization be obtained prior to the services being rendered. 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 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 skilled nursing care provided from June 1, 2020, to June 30, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive metabolic panel (CPT code 80053) provided on October 13, 2020, at the outpatient department of the hospital.
You asked the Plan to waive the copayment for the outpatient diagnostic testing. You say that you were assessed a copayment for blood work during your annual wellness visits. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a comprehensive metabolic panel on October 13, 2020. You were asked to pay a $5 copayment for the outpatient diagnostic testing. The health plan contract says that enrollees must pay a $5 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Furthermore, your 2020 EOC states, "physician or specialist cost-sharing may apply for any non-preventive services rendered at the time of visit. Diagnostic testing will be subject to diagnostic cost-sharing." 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 comprehensive metabolic panel (CPT code 80053) provided on October 13, 2020, at the outpatient department of the hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96413, 96415) provided on July 30, 2020.

You asked the Plan to pay for chemotherapy administration. You say that these codes are appropriate for more than chemotherapy. The Plan denied your request. The Plan says these codes are not correct for the service provided.

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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The definition of 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure). 

We find that CPT codes 96413 and 96415 are not supported in the medical record. Specifically, these codes are used to report chemotherapy administration, but the records show that the drug administered on this date of service is not a chemotherapy drug. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413, 96415) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and progressive lens (V2781) provided September 10, 2020.

You asked the Plan to pay for the frames and lenses. You say that you thought the glasses would be covered and cannot afford the cost. The Plan denied your request. The Plan says that since the eyewear was purchased from an OON provider, they are not covered.

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. The Plan covers these services when they are purchased from a network provider. 

We looked at the file and the Plan's rules. The provider in this case is not a network provider with the Plan at the time of the service. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and progressive lens (V2781) provided September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 were admitted for syncope and was treated for a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral/facial photographic images (D0350 x 4) provided on
November 20, 2020.
You asked the Plan to pay for the dental services. You say that the enrollee went in for a pre-screen visit. You
say that you did not receive a financial agreement until 3 weeks later. You say that the enrollee received a bill
for $408. You say that you do not understand why. You say that you cannot get ahold of anyone to explain this
to you. You also say that you would like to get a credit so that the enrollee can go to another dental office. The
Plan denied your request. The Plan says oral/facial photographic images are not listed as covered services. The
Plan also says that the enrollee did not contact the Plan prior to the date of service to verify benefits or provider
eligibility.
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. Therefore, we decided that the Plan does not have to pay for the
oral/facial photographic images (D0350 x 4) provided on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 31, 2019 to November 4, 2019.

You asked the Plan to pay for acute inpatient hospital care. 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. 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 looked at the file and Medicare rules. Review of the file shows that no medical records were submitted to the Plan. Medical records are required to support medical necessity of the services rendered. Since no medical records were provided, medical necessity of the services rendered cannot be determined. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided October 31, 2019 to November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home (99336) visit provided on December 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for domiciliary or rest home visit. You say that the provider should not be penalized for the hospital not obtaining authorization. The Plan denied your request. The Plan says authorization is required for OON services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home (99336) visit provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 22, 2020.
You asked the Plan to pay for the 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 had network providers available who could have provided 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 for the services provided to the enrollee by an out-of-network provider on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on December 11, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for in-network specialist's office services.
Review of the file shows that you received specialist services on December 11, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the in-network specialist's office 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 specialist services rendered on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says a lesser level of care can allow for measurable gains.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for nausea, vomiting and diarrhea and was treated for an intestinal infection. Her medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on December 28, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21. We looked at the file and Medicare rules. The file shows that procedure code 00732 (anesthesia for upper gastrointestinal procedures) was billed with POS code 22 for outpatient hospital; however, the enrollee was under inpatient status for the date of service at issue. 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 anesthesia services rendered on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) unit provided July 1, 2020, to December 1, 2020.

You asked the Plan to pay for the TENS unit. You say that this device was medically necessary for your condition. The Plan denied your request. The Plan says this device was not medically necessary as you were not enrolled in a clinical trial.

The Plan follows Medicare rules. Medicare rules say that TENS unit therapy is subject to the coverage criteria listed 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 pay for the TENS unit. Our reviewer says that this requested service was not medically reasonable and necessary. Our physician reviewer found you are a 73-year-old female who had a stem cell injection in the lumbar spine and afterwards it was recommended that you use a TENS unit. In this case, the coverage criteria for the TENS unit have not been met. The documentation does not indicate that you are using this for postoperative pain. The documentation does not reveal evidence of a diagnosis that would necessitate you being enrolled in a clinical trial. 

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 TENS unit have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) unit provided July 1, 2020, to December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for massage therapy provided from June 15, 2020, through July 22, 2020.

You asked the Plan to reimburse you for the massage therapy. You say that your PCP had prescribed massage therapy to help with your arthritis and lower back pain. The Plan denied your request. The Plan says this provider is an out-of-network massage therapist and does not have a registered NPI number. Per CMS guidelines, licensed massage therapists are not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that a Licensed Massage Therapist is not eligible to participate in the Medicare program. 

We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Massage Therapist. Medicare says that a Licensed Massage Therapist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for massage therapy provided from
June 15, 2020, through July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture (36415) provided on October 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON venipuncture. You say that you have never been charged for this service in the past. The Plan denied your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for venipuncture (36415) provided on October 19, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the member no longer requires daily skilled therapy to be delivered by
licensed therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for continued SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar brace provided on October 9, 2020.
You asked the Plan to pay for the provided brace. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lumbar orthoses are only covered under certain medical indications. We looked at the file and Medicare rules. In this case, there is insufficient documentation of the enrollee's medical condition to substantiate the necessity for the brace. There are no medical records that provide objective findings or a previous physical exam that documents instability, injury, or a surgical procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar brace provided on October 9, 2020.