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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 currently undergoing treatment at an acute care hospital (ACH) for shortness of breath related to chronic obstructive pulmonary disease (COPD), PEs and metastatic colon cancer. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The enrollee has a poor prognosis and is not being offered additional treatment for their cancer. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of broken teeth and endodontic therapy provided on January 9, 2020 and January 16, 2020.You asked the Plan to pay for the replacement of broken teeth and endodontic therapy. You say that after these services were rendered, you were told that your insurance Plan only had dental insurance for 2019. You also say that you never received a notice stating that the dental insurance was only for 2019.The Plan denied your request. The Plan says these dental services are not included on your benefit plan and are not covered services.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 replacement of broken teeth and endodontic therapy provided on January 9, 2020 and January 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you more forthe resin-based composite, bitewings, periodic oral evaluation, prophylaxis provided on September 30, 2019.You asked the Plan to reimburse you more forthe resin-based composite, bitewings, periodic oral evaluation, prophylaxis. You say that the Plan says that they will pay up to $600 as long as you pay first and send them your paid bill. You also say that you have been paying $23.99 per month for this insurance and want to be reimbursed the remaining balance of the $600 allowance.The Plan denied your request. The Plan says you have already been reimbursed the full amount that you paid to the 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, the requested items or services are not among those covered under this benefit. Your dental benefit does not entitle you to reimbursement for monies paid to be enrolled in a plan.Therefore, we decided that the Plan does not have to reimburse you more forthe resin-based composite, bitewings, periodic oral evaluation, prophylaxis provided on September 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the service provided. The Plan denied your request. The Plan says the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure. We find that the billed train of four testing is included in the payment for neuromonitoring services already paid for by the plan. Based on this information, we decided that Medicare rules for coverage of the service provided have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided to the enrollee on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient services provided on October 15, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 forthe outpatient services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies provided on June 6, 2019.
You asked the Plan to pay for the IV home infusion supplies, (A4221, A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no valid physician order, or itemized shipping/billing invoice to indicate the specific supplies or Proof of Delivery indicating the billed items were delivered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The physician order does not specify the supplies and there is no proof of delivery. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe aminophylline injection coded J0280 provided on October 29, 2019.You asked the Plan to pay forthe aminophylline injection. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the services billed are not supported by the documentation.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 J0280 is injection, aminophylline, up to 250 mg.We find that CPT code J0280 is not supportedin the medical record. Specifically, 3 units of this code were billed. The documentation submitted shows that 75mg of aminophylline was given. Therefore, three units of this code are not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the aminophyllineinjection have not been met.Therefore, we decided that the Plan does not have to pay forthe aminophylline injection coded J0280 provided on October 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weekly skilled nursing visits to be provided in the home health setting requested on January 18, 2020.
You asked the Plan to pre-approve the weekly home health services. You say that the enrollee needs this weekly nursing care to maintain his condition. The Plan denied your request. The Plan says criteria are not met for this home health care and the services are being covered by a different benefit program.
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 the weekly home health services. Our reviewer says that the resumption of once weekly skilled nursing visits for certification period beginning 1/18/2020 is not shown to be medically necessary. Our physician reviewer found a 12/6/19 nursing note reveals wound care provided was cleansing with saline, applying hydrophilic cream and covering with Mepilex. Wound care was to continue for the right and left buttock until healed. A 1/16/20 wound care note reveals the wounds were clean, dry, intact and stage 1 without drainage and odor. A 1/13/20 RN note reveals the left wound on the buttock was healed. Per a 1/18/20 RN visit the patient has 2 stage 2 pressure ulcer. They are located on the right buttock and the left buttock and are cleansed with normal saline, dressed with triad paste and covered with mepilex.
The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient beyond what was approved by the health plan. There are no complex wounds, IV medications, new enteral feedings or other skilled nursing need that requires ongoing skilled nursing visits for this patient. The patient was instructed on safety, diet, medication and disease management. There are no ongoing professional skilled nursing needs. 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 weekly home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve weekly skilled nursing visits to be provided in the home health setting requested on January 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine fusion.
You asked the Plan to pre-approve the spinal surgery. The Plan denied your request. The Plan says this 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 spinal surgery. Our reviewer says that the requested spinal surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no evidence of spinal fracture, instability, or tumor documented by the records provided. 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spine fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on July 18, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 podiatry services provided on July 18, 2018 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Mesalamine provided on December 25, 2019.You asked the Plan to pay forthe Mesalamine. You say that this drug was falsely stated as being self-administered. You also say that a nurse administered this drug.The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that you were notified prior to the service being performed.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Mesalamine provided on December 25,2019.Benefits forMesalaminemay be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam and dental x-rays you received on January 17, 2020.
You asked the Plan to pay for the dental services. You say that you were unaware you would be charged for the services. The Plan denied your request. The Plan says services are only covered for in-network dentists.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. The records show that you received dental services from a non-participating provider. Your plan only covers supplemental dental services from participating providers. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the oral exam and dental x-rays you received on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, periodontal maintenance, and
bitewings provided on October 25, 2019.
You asked the Plan to pay for the periodic oral evaluation, periodontal maintenance, and bitewings. You say
that you signed a form at the dental office that said you would be reimbursed by the Plan for the services. You
also say that you have not received a refund due to an error code. The Plan denied your request. The Plan says
the provider had opted out of Medicare prior to this date of service. The Plan also says that they are unable to
make payments for services provided by a dentist who has opted out of Medicare under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has
opted out of the Medicare program. The file shows that this provider entered into a private contract with you
regarding payment. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation,
periodontal maintenance, and bitewings provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided from October 30, 2019 to November 1, 2019.
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the chiropractic treatment. 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 chiropractic treatment provided from October 30, 2019 to November 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit provided on November 9, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ERvisit. An ER visit falls within the emergency care 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 foran ER visit provided on November 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on July 29, 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 procedure code 99152 is 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 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 moderate sedation services rendered on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve duplex scan extremity tests.
You asked the Plan to pre-approve extremity tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee has not had a clinical assessment in almost 1 year and a similar study was already approved for the enrollee.
The Plan follows Medicare rules. Medicare rules say that non-invasive peripheral arterial vascular studies are only covered for certain indications when they are medically necessary. 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 extremity tests. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested extremity tests. Our physician reviewer found in this case, the issue is not the necessity of some form of surveillance imaging, but rather the specific tests requested. The enrollee has a known bypass graft for which yearly surveillance is indeed reasonable. The enrollee also has known arterial occlusive disease that has been previously categorized and further duplex imaging would not provide any information that would change the plan in the absence of new symptoms. Multilevel arterial dopplers and bilateral lower extremity arterial duplex for surveillance is excessive. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extremity tests have not been met. Therefore, we decided that the Plan does not have to pre-approve duplex scan extremity tests.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CPT code 74176 provided on December 4, 2019.
You asked the Plan to pay for CPT code 74176. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the case file does not contain evidence that CPT code 74176 cannot
be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains
the CPT code 74177 that the health plan states CPT code 74176 is bundled with. It cannot be verified that
payment for CPT code 74176 is bundled with another procedure that was billed on the same date of service.
Therefore, we decided that the Plan has to pay for CPT code 74176 provided on December 4, 2019.