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

We decided that the Plan does not have to pay forthe hospital outpatient clinic visit provided on January 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the enrollee is refusing to change care due to her insurance.The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 providersonly 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe hospital outpatient clinic visit provided on January13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on January 14, 2020.
You asked the Plan to pay for a shoulder brace. You say that this sould be paid. The Plan denied your request. The Plan says the documentation does not indicate this was 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 pay for a shoulder brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination showed decreased range of motion with pain. An x-ray was done that was reportedly "unremarkable." The records do not substantiate medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder brace have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on January 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 skilled home health visits.You asked the Plan to pre-approve 9 skilled home health visits. 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. 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 9 skilled home health visits. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation does not reveal complex wound care, IV antibiotics,new enteral feedings. The enrollee has been educated on his chronic disease processes and can get further education and medication education from his physician follow ups. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Therefore, the enrollee does 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 9 skilled home health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve 9 skilled home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transport for a total of 75 miles.You asked the Plan to pre-approve these services. You say that you need to have your blood drawn and your port taken care of.The Plan denied your request. The Plan says the request exceeds the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 36 one-way trips and each trip must not exceed 50 miles. We looked at your request, the case file, and the rules. You are requesting a one-way trip for a total of 75 miles. This exceeds the benefit limit of 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine transport for a total of 75 miles.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) and train of four testing (95999) provided on March 1, 2019.

You asked the Plan to pay for needle electromyography and train of four testing. You say that this should be covered. The Plan denied your request. The Plan says these codes 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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. Code 95999 is an unlisted neurological or neuromuscular diagnostic procedure.

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 needle electromyography and train of four testing. Our reviewer says that the services were not billed correctly. Our physician reviewer found needle electromyography monitoring was performed on the "upper abs" and "lower abs" (i.e. non-extremity/axial muscles) supporting two units of CPT 95970, but three were billed. Train of four monitoring is considered part of the overall monitoring codes (95940, 95941), does not have its own billing code and is not separately billable. Therefore, the billing of 3 units of CPT and CPT 95999 for train of four testing is not supported.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography and train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) and train of four testing (95999) provided on March 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe next generation sequencing (NGS) provided on September 13, 2019.You asked the Plan to pay forthe NGS.You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee does not have either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The testing was performed to determine medication choices.Therefore, we decided that the Plan does not have to pay forthe next generation sequencing (NGS) provided on September 13, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical extraction (D7210) for tooth # 29 and inhalation of nitrous oxide (D9230).You asked the Plan to pre-approvethe dental services. You say that your tooth is badly damaged. You say that it is infected. You also say that you are in a lot of pain.The Plan denied your request. The Plan says 6 extractions per calendar year are covered. The Plan says the benefit limit for extractions has been exhausted. The Plan also says that the inhalation of nitrous oxide is only covered when the associated service is approved.Medicare generally does not cover dental services. However, thePlan 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 and extractions are a covered service, the benefit limit of6 per calendar year has been exhausted. The record shows that the Plan previously paid for 6 extractions that you received on February 26, 2020.Additionally, since the requested extractions is not covered, the associated inhalation of nitrous oxide is also not covered.Therefore, we decided that the Plan does not have to pre-approvea surgical extraction (D7210) for tooth # 29 and inhalation of nitrous oxide (D9230).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the Head (70450) provided
November 27, 2019.
You asked the Plan to pay for the CT scan. You say that the service was medically necessary and correctly
billed. The Plan denied your request. The Plan says the service was billed with an improper place of service.
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 70450 is not supported in the medical record. Specifically, a routine service was billed
with the place of service listed as an Emergency Room. Based on this information, we decided that Medicare
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay
for Computed Tomography (CT) of the Head (70450) provided November 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysservices can be received in another care setting, such as a SNF.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 ACH after falling down a flight of stairs resulting in multiple traumatic injuries. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He has only recently become more alert and is starting ventilator weaning trials. 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 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services you received from January 12, 2018 to December 4, 2018.You asked the Plan to pay for the outpatient services. You say that you have made great progress with using talk therapy and medication.The Plan denied your request. The Plan says the provider submitted the claim after timely filing limitations.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that the claims for the outpatient services were not filed until December 10, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the outpatient mental health services you received from January 12, 2018 to December 4, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 8, 2020.
You asked the Plan to pay for the provided items. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the billed items.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical indications. 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 provided items. Our physician reviewer found that the documentation does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case. There is no documentation that the enrollee has had recent injury to or a surgical procedure on the knees. There is no documented knee instability due to a specific condition. There is no objective documentation of joint laxity. Furthermore, the suspension sleeves are not separately payable when the base item is not covered. 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 provided items have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen/pelvis.You asked the Plan topre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 wascorrect 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 reports ongoing left lower quadrant (LLQ) pain following a colonoscopy and upper endoscopy. A progress note dated February 6, 2020 notes discomfort in the LLQ. The vital signs are incomplete, and there are no laboratory studies or discussion of a differential diagnosis. The provider documented hematochezia, but there is no documentation of guiaic or stool studies. The documentation does not support that the CT scan is reasonable and medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have weak leg muscles and would like to prevent slipping and falling in the shower. The Plan denied your request. The Plan says that a bath/shower chair is non-covered with Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (Q4050, L3000).
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (Q4050, L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member was self-directed for these services. The Plan says that no prior authorization was obtained. The Plan says that there are in-network alternate providers available 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 for vision services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 22, 2019 to December 24, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were in the emergency room department and not the intensive care unit.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 $370 copayment per day for days 1-5 for inpatient hospital care. You received an inpatient hospital stay from December 22, 2019 to December 24, 2019. Therefore, you are responsible to pay a $370 copayment for days 1-2 (December 22, 2019 to December 23, 2019). $370 (copayment) x 2 (inpatient days) = $740. You have been asked to pay total copayment amount of $740 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay provided from December 22, 2019 to December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says this is covered if you are on home dialysis.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor for the
enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are medically 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 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 correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.