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

We decided that the Plan does not have to waive the coinsurance for the drug testing provided to you on July 3, 2019.
You asked the Plan to waive the coinsurance. You say that you shouldn't have to pay for a state mandated drug screening. The Plan denied your request. The Plan says you are responsible for the cost share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for non-standard Medicare-covered outpatient lab tests, such as drug screens. Review of the file shows that you were provided drug testing services on July 3, 2019. The Medicare allowed amount for these services is $179.08. You have been asked to pay a 20% coinsurance for the drug testing, totaling $35.82 ($179.08 x 20% = $35.82). The drug testing falls 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 coinsurance for the drug testing provided to you on July 3, 2019.
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 the LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says that transfer to aLTACH is not medically necessary as the enrollee is receiving appropriate care a tthe present acute care facility.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 that the member does not require mechanical ventilation management. She does not require extensive or complex wound care management by skilled nursing of at least 6.5 hours per day. Additionally, the member does not have a permanent and stable feeding source at this time.The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 health plan.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on April 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that you are very debilitated and believe that skilled care in a SNF is necessary.The Plandenied your request. The Plansaysthe enrollee has no skilled nursing needs and would not benefit from daily therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted due to heart failure. A transesophageal Echocardiogram done 2 days before showedfindings of very severe tricuspid regurgitation. His hospital course was complicated by acute kidney injury on chronic kidney disease and gastrointestinal bleeding. The member does not have skilled nursing needs. The member is not receiving IV medications or fluids. Routine monitoring of his chronic medical conditions is being done. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. There are skilled therapy needs. The member requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the 
need for any adaptive equipment. However, this therapy is not required on a daily basis. The member has been able to ambulate greater than household distances and is performing essential activities of daily living without hands on assistance. The member's condition would not be expected to deteriorate with services provided on aless than daily basis.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 SNF admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea 13-month rental of a Group 2 powered pressure reducing air mattress (E0277).You asked the Plan to pre-approvethe mattress. You say that the one you have now is broken, has air pockets, and is extremely uncomfortable.The Plan denied your request. The Plan says Medicare coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that a Group 2 support surface is covered if the enrollee has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis, or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. We looked at the file and Medicare rules. In this instance, the records do not support a documented pressure ulcer. Based on this information, we decided that Medicare rules for coverage of the mattress have not been met.Therefore, we decided that the Plan does not have to pre-approvea 13-month rental of a Group 2 powered pressure reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair and accessories. You say that you have health issues and a wheelchair would be very helpful to your situation.The Plan denied your request. The Plan says documentation does not show you are unable to use a manual wheelchair or that you are unable to safely operate and use a power scooter. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating there quested PMD. The file does not show that your condition canno tbe improved by a walker, cane or manual wheelchair, or you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Cx bladder testing rendered on October 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.The test at issue is CxBladder. This test is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe Cxbladder testing rendered on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forobservation care provided on August 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forobservation care. You say that you would like these claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 has network providers available who can provide 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 forobservation care provided on August 24, 2019 by an out of network (OON) provider.
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-approveIRF care. You say that the enrollee's acute and chronic conditions require daily medical oversight, and rehab therapy.The Plan denied your request. The Plan says the enrollee does not require active and ongoing therapeutic intervention of multiple therapy disciplines.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 carefullyreview 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 has a history notable for left hemisphere stroke. The most recent hospital admission was due to altered mental status. The records now indicate the enrollee is sleeping better, but she reports fatigue with activity. Hemodynamics and neurological status are stable. 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 is at standby to contact guard assist for functional transfers and activities of daily living. The enrollee does not  require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on January 15, 2019.You asked the Plan to pay forthe periodontal maintenance. You say that this procedure has been a reimbursable expense for several years. You also say that you are requesting a reimbursement of $91 that would bring the total approval up to the allowable maximum of $150 under your health insurance plan.The Plan denied your request. The Plan says thisservice is excluded from coverage.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 forthe periodontal maintenance provided on January 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean advanced lymphedema arm pump device (E0652, E0668).You asked the Plan to pre-approvean advanced lymphedema arm pump device. You say that the requested items 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. 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 advanced lymphedema arm pump device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found on careful review of records, the enrollee does not meet the criteria for a provision of a Flexitouch Pneumatic Compression device as requested and justified in the note dated December 12, 2019. She has not tried at least four weeks of regular, daily, multiple hour home usage of the pneumatic compressor (E0650) or pneumatic compressor, segmental home model without calibrated gradient pressure (E0651). Having tried just only one time, she did not fulfill the coverage criteria of trying and failing a 30-day 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 an advanced lymphedema arm pump device have not been met.Therefore, we decided that the Plan does not have to pre-approvean advanced lymphedema arm pump device (E0652, E0668).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe bitewing x-rays (D0274) and the panoramic x-ray (D0330) provided on October 31, 2019.You asked the Plan to pay the full amount forthe dental services. You say that the services should be covered as they were needed to diagnose the work that needed to be done. You say that the dental office should have known the services would not be covered. You also say that paying for the services would be a financial hardship for you.The Plan denied your request. The Plan says the provider in this case is not a plan provider. The Plan also says that you are responsible for the difference between the dentist's fees and the Plan's dental fee schedule.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, for dental services that you receive out of network you are responsible for the difference between dentist's fees and the Plan'sdental fee schedule.Therefore, we decided that the Plan does not have to pay the full amount forthe bitewing x-rays (D0274) and the panoramic x-ray (D0330) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveposterior tibial nerve stimulation for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansays50% decrease in overactive bladder symptoms on the initial course was not achieved.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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records does not support a more than 50% improvement in symptoms, which is required for coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveposterior tibial nerve stimulation for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.You asked the Plan to pre-approve the compression stockings. You say that you have varicose veins and they hurt.The Plan denied your request. The Plan says you do not have a covered indication for the compression stockings requested.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 27, 2019 to March 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for the hospital services. You say that the services rendered were medically necessary. The Plandenied your request. The Plan says this provider is outside of the member's network of providers and prior authorization was not obtained from the Plan.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 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 the medical services provided on February 27, 2019 to March 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe power wheelchair upgraded electronics or power seat elevation feature.You asked the Plan to pre-approvethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), and power seat elevation feature (E2300). You say that the enrollee needs the power wheelchair upgraded electronics and power standing feature.The Plan denied your request. The Plan says thepower seat elevation feature is not covered and the upgraded electronics are not necessary as there is only one approved power option. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), and power seat elevation feature (E2300)have not been met.Therefore, we decided that the Plan does not have to pre-approvethepower wheelchair upgraded electronics or power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the complete series of periapical x-rays (D0210), the crown (D2750), and the prophylaxis (D1110) provided from October 17, 2019 to November 6, 2019.You asked the Plan to pay forthe crown. You say that when you paid your balance for the service on November 6, 2019, you were advised there would be no more charges.The Plan denied your request. The Plan says dental services that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider.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, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to pay forthecomprehensive oral evaluation (D0150), the complete series of periapical x-rays (D0210), the crown (D2750), and the prophylaxis (D1110) provided from October 17, 2019 to November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical assistant services on laparoscopic procedures (38571 and 55866) provided on March 6, 2019.You asked the Plan to pay forsurgical assistant services. You say that these services were ordered for the enrollee's safety.The Plan denied your request. The Plan says surgical assistant services arenot covered when provided by a CSA.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forsurgical assistant services on laparoscopic procedures (38571 and 55866) provided on March 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on August 16, 2018.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary neuromonitoring procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on August 16, 2018.