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

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient psychiatric services. The Plan denied your request. The Plan says based on Medicare guidelines, the mental health inpatient psychiatric services you and/or your provider are requesting do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric services.
Our reviewer says that inpatient psychiatric services are not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, hallucinations, or aggressive behaviors. The health Plan's denial of continued inpatient psychiatric services appears appropriate. You did not require inpatient mental health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 27, 2021 forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and you were not showing any aggressive behaviors being cooperative and compliant as you awaited placement. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pre-diagnostic test (D0431) provided on March 31, 2020.

You asked the Plan to pay for the pre-diagnostic test (D0431). You say that the dental office was previously in-network and were attempting to regain network status since November 2020. You say that the appointment should have been covered and the denial should be reversed. The Plan denied your request. The Plan says the periodic oral evaluation and prophylaxis will be paid, and the pre-diagnostic test is not a covered benefit.

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 pre-diagnostic test (D0431) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pre-diagnostic test (D0431) provided on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device from an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that there is no other provider that supplies the prescribed equipment. The Plan denied your request. The Plan says there are network providers available.
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 there are no extenuating factors that would require an out of network E0652 pump and E0667 pneumatic appliance as the plan indicates that at least equivalent devices are available in network. 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 Plan does not have to pre-approve a pneumatic compression device from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection and specialist services provided by a participating provider on January 6, 2021, to March 16, 2021.

You asked the Plan to waive the copayment for an injection and specialist services. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $100 copayment for outpatient surgery/in-network and a $20 copayment for physician/practitioner services/in-network/specialist.

You have been asked to pay a $100 copayment for an injection and a $20 copayment for specialist services. The total amount you are being asked to pay is $360 (($100 x 3 surgeries = $300) + ($20 x 3 visits = $60) = $360). An injection falls within the outpatient surgery/in-network benefit category and specialist services falls within the physician/practitioner services/in-network/specialist 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 an injection and specialist services provided by a participating provider on January 6, 2021, to March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand glucose meter.

You asked the Plan to pre-approve the requested glucose meter. You say that the enrollee noticed a difference in the result with the preferred brands. The Plan denied your request. The Plan says the non-preferred product 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 the requested glucose meter. Our physician reviewer found that the records indicate the enrollee has tried a OneTouch device and a Freestyle device and notices lower results with the Freestyle device. The records do not address the Accu-Check device. Nothing in the provided records clarifies that the plan's preferred products (OneTouch and Accu-Check) would likely be less effective for the enrollee. The records do not provide data indicating the requested device is more accurate than the plan's preferred products. 

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 requested glucose meter have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand glucose meter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (75574) provided February 11, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that the hospital billed you $170 copay for a CT scan. You should not have a copay for an in-network test in an in-network facility requested by an in-network physician. The Plan denied your request. The Plan says the claim was processed with the correct copayments 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 for each diagnostic radiology service $150 for each visit to an outpatient hospital facility.
You have been asked to pay $170 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies and Outpatient hospital services 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 computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (75574) provided February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on March 5, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you have $2,500 worth of coverage and this is covered at 50%. The Plan denied your request. The Plan says the service is not a covered benefit.
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 limited oral evaluation provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (0376T).
You asked the Plan to pre-approve insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Only one unit per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date of service. 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 insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion. Our reviewer says that the service is not medically necessary. Our physician reviewer found a single delivery system, such as the planned iStent, can provide two such stents. Only one unit per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date 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 insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion have not been met. Specifically, only one unit per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date of service. This means insertion of an additional anterior segment aqueous drainage device is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (0376T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the nitrous oxide (D9230) provided on March 25, 2021.

You asked the Plan to pay for the nitrous oxide (D9230). You say that if you hadn't received the nitrous oxide you would not have been able to have your teeth pulled. You say that this should be paid. The Plan denied your request. The Plan says the service is not a covered benefit.

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 nitrous oxide (D9230) provided on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 21, 2020.
You asked the Plan to pay for laboratory services. You say that this was denied in error. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
provided on March 25, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it would
have cost more if you had been treated at the hospital. The Plan denied your request. The Plan says you were
offered transport to the hospital but declined twice. The Plan also says that you provided your signature to
confirm non-transport.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 25, 2021. The documentation shows that you were offered to be transported twice but declined. As such, the conditions of the waiver have not been met. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need help with walking and standing. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy in a SNF setting.
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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a maximal assist dependent level with bed mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous device surgery.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that this treatment is considered safe and effective. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The requested device is contraindicated in individuals with morbid obesity defined as a body mass index (BMI) greater than 40. In this case, the enrollee indicates that the enrollee has chronic lumbar spinal stenosis and neurogenic claudication. The record indicates that the enrollee has a BMI of 42.1. The device is contraindicated in individuals with morbid obesity defined as a body mass index (BMI) greater than 40. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous device surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on February 4, 2021 by an out-of-network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
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 the pathology services provided on February 4, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on February 1, 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 three units of procedure code 75774 are not supported.
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 75774 is angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure). We find that CPT code 75774 is not supported in the medical record. Specifically, the records do not support the billing of three units of this code 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 imaging services rendered on February 1, 2021.