Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care visit, 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the provided records do not 
detail how much time was spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive periodontal evaluation 
(D0180) provided on February 18, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you needed a consult for a procedure 
for your receding gums. You say that the provider is in network. You also say that the you would like to be 
reimbursed for the consulting fee. The Plan denied your request. The Plan says the comprehensive periodontal 
evaluation 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. Therefore, we decided that the Plan does not have to reimburse you for 
the comprehensive periodontal evaluation (D0180) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested bone marrow aspirate is
medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspirate is 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 pre-approve bone marrow aspirate. Our reviewer
says that the requested bone marrow aspirate is not medically necessary. Our physician reviewer found bone
marrow aspirate remains experimental for use in spine fusion surgery. More research is needed to show safety
and efficacy. Iliac crest bone graft is the gold standard for fusion bone graft.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation provided on January 8, 2020. 
 
You asked the Plan to pay for the ambulance transportation. You say that you could not have gotten the 
medical care you needed any other way because you were too weak to manage other methods of transportation. 
The Plan denied your request. The Plan says that this was billed as noncovered transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
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 ambulance transportation. Our reviewer 
says that the documentation supports that the enrollee's condition meets the definition of an emergency. Our 
physician reviewer found the enrollee was ill with fever, chills, and weakness. She had not responded to a 
course of oral antibiotics. Given the symptoms and prior treatment, the enrollee was potentially severely ill and 
required immediate medical care. Transportation by ambulance was reasonable and 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 ambulance transportation have been met. Therefore, we decided that the 
Plan has to pay for the ambulance transportation provided on January 8, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity ofservices provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic, prophylactic, or diagnostic 
injection (97362) Denosumab injection (J0897) provided June 22, 2020. 
 
You asked the Plan to waive the copayment for the injection services. You say that you had applied for 
financial assistance with the hospital, which was approved. You are dissatisfied with the financial assistance 
amount that the hospital determined is the balance due amount. The Plan denied your request. The Plan says 
the correct copayment was applied per the Evidence of Coverage. 
 
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 20% 
coinsurance for each Part B drug and $395 copayment for surgery or other services provided at an ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $289.82 ($232.06 + $57.76) for the injection services. For 97362 the allowed 
amount is less than the Outpatient hospital service copayment amount of $395. Since the allowed amount is 
less than the copayment amount, you are responsible for lesser amount applied. The injection service falls 
within the Medicare Part B Prescription drugs and Outpatient surgery and other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit categories. 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 therapeutic, prophylactic, or diagnostic injection (97362) Denosumab injection 
(J0897) provided June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implantable loop recorder.You asked the Plan to pre-approvean implantable loop recorder. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 pre-approve an implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports that you had one syncopal spell with a negative evaluation and no recurrence in the subsequent 7 months. Since there is not "recurrent" syncope and you have been stable with a negative initial evaluation the records do not support the medical necessity for an implantable loop recorder at this time. Implantable loop records are usually considered if there is "recurrent" unexplained syncope. Therefore, you do not meet criteria for the requested 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 an implantable loop recorder have not been met.Therefore, we decided that the Plan does not have to pre-approvean implantable loop recorder
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity ofservices provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-ray services provided on October 7, 2020. 
 
You asked the Plan to waive the copayment for the x-ray services. You say that the facility was not clean so 
you should not have a copayment. The Plan denied your request. The Plan says you were charged this 
copayment 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 $60 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $60 copayment for the x-ray services. The x-ray services fall within the 
outpatient diagnostic tests 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 x-ray 
services provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on September 17, 2020.You asked the Plan to pay forthe dental services. You say that you did not know that you had to wait 3 years before you could go to see a dentist to get your teeth taken care of. You say that you do not remember what you had done in 2018, the last time you went to the dentist. You say that your crown fell out and you needed to see the dentist. You also say that this has been very stressful for you.The Plan denied your request. The Plan says 1 comprehensive oral evaluation and 1 panoramic x-ray are covered every 3 plan years. The Plan says that the frequency limits for these services have been exceeded.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, frequency limit for these services have been exceeded. The record shows that the Plan paid for these services that you received on January 25, 2018.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on September 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical pathology services (88361, 88312, 88305, and 88104) provided on June 17, 2020.You asked the Plan to pay forthe surgical pathology services. You say that you would like reconsideration because these services were medically necessary.The Plan denied your request. The Plan says the professional interpretation of a diagnostic test must be billed separately billed with modifier -26 by the interpreting physician.The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Specifically, the codes at issue have a PC/TC indicator of 1 meaning they are diagnostic services. The codes have not been billed with the appropriate modifier to indicate that these were professional components of these services.Therefore, we decided that the Plan does not have to pay forthe surgical pathology services (88361, 88312, 88305, and 88104) provided on June 17, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four home health occupational therapy (OT) visits. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says four visits are approved but four further are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has been medically stable without any recent exacerbations of chronic medical problems. She had an acute illness that resulted in a decline in function but has made gains with therapy. She does not require additional occupational therapy services to effectively provide treatment, care, and/or services in order to improve her condition or a maintenance program to maintain or prevent deterioration of her condition. The four approved visits are reasonable to establish an effective home exercise program. Four further 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve four home health occupational therapy (OT) visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for post stabilization care provided from July 8, 2020, through July 13,
2020.
You asked the Plan to pay for post stabilization care. You say that the service was medically necessary. The
Plan denied your request. The Plan says that the service was not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post stabilization care. Our reviewer says
that the service was medically necessary. Our physician reviewer found that the treating physician did
document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any
dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of post stabilization care have been met. Specifically, the treating physician noted
the enrollee was not stabilized for transfer on any date of service. This means the services were medically
necessary and reasonable. Therefore, we decided that the Plan has to pay for post stabilization care provided
from July 8, 2020, through July 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tertiary-level neurology referral.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no indication of why this service needs to be completed at a tertiary facility.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 pre-approve the referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you had previously been seen by an ENT who suspected migraines (and referred her to neurology). It does not appear from the records provided for review that you have had a prior evaluation for migraines. There are otherwise no unique circumstances in the records that readily suggest that you requirea tertiary level evaluation for migraines. Rather, such a consult would otherwise exceed your medical need at this time, compared to evaluation from a community provider. Consequently, it cannot be said that the requested service would be reasonable and necessary at this interval.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 referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tertiary-level neurology referral
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from June 26, 2020, to September 1, 2020.
You asked the Plan to waive the copayments for physical therapy. You say that you were not told there would be a copayment for the approved therapy visits. The Plan denied your request. The Plan says you were charged the copayments 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 $15 copayment for Outpatient Rehabilitation Services. You have been asked to pay a $15 copayment for each physical therapy visit. Physical therapy falls within the Outpatient Rehabilitation 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 copayments for physical therapy provided from June 26, 2020, to September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 29, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring
provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on November 29, 2019 by an
out of network (OON) provider.