Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy evaluation (97166) and therapeutic activities (97530) provided December 15, 2020 to December 30, 2020.
You asked the Plan to waive the copayment for the outpatient therapy services. You say that you paid $35 for each date of service and is now receiving a bill from the provider for an extra $5 for each date of service. You did not have occupational therapy and don't feel you should be responsible to pay. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $40 copay per provider, per day for occupational therapy services.
You have been asked to pay $80 for the outpatient therapy services. The outpatient therapy services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the occupational therapy evaluation (97166) and therapeutic activities (97530) provided December 15, 2020 to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services coded 90837 provided on February 2, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 90837 is psychotherapy, 60 minutes with patient. We find that CPT code 90837 is not supported in the medical record. Specifically, this service was billed with the primary/first diagnosis code of F06.4 (Anxiety disorder due to known physiological condition). This means this service was billed with an appropriate primary, first-listed or principal diagnosis.
A secondary only diagnosis code cannot be used as the primary, first-listed or principal diagnosis for any procedure. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services coded 90837 provided on February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reconstruction services.
You asked the Plan to pre-approve the requested services. You say that the enrollee has persistent scarring that
affects movement of her right arm. The Plan denied your request. The Plan says the service is primary cosmetic
and not a covered benefit.
The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is 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 pre-approve the requested services. Our physician reviewer found that in this case, the enrollee underwent augmentation for cosmetic purposes 30 years ago and has had revisions due to capsule contracture and scarring. The medical records indicate that the requested procedure is not being performed for restoration of function nor to remove the implants. The medical records indicate that further procedures may not address the concerns of the enrollee. The provided records do not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reconstruction services.
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-approve IRF care. You say that you need intensive therapy to get back to being more independent. The Plan denied your request. The Plan says it is not clear the enrollee would be able to actively participate in 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our physician reviewer found that you were admitted to the acute care hospital for confusion, rhabdomyolysis, acute kidney injury and has been discharged to a skilled nursing facility. Your medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. You do not require treatment by multiple therapies, including either physical 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 was admitted following a cardiac arrest with persistent acute respiratory
failure. The enrollee remains on a ventilator requiring intermittent pressor support. The enrollee is clinically
unstable with acute kidney injury and anoxic encephalopathy. The enrollee continues to receive acute critical
care services, and these have not been denied. The medical record does not indicate that the enrollee requires
services that they are not currently receiving but that would be available at the LTACH facility. The elements
of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the member liability for the oral exam (D0120), prophylaxis (D1110), the core build up (D2950), crown (D2750), and the filling (D2391) provided from November 25, 2020, to December 16, 2020.
You asked the Plan to waive the member liability for the dental services. You say that these services were an emergency. You also say that you were misled to believe that the providers were in network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network have a higher cost share amount. The Plan says there is an annual maximum benefit of $1,000. The Plan also says that the annual maximum has been exhausted.
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 and the services are listed as covered, dental services performed out of network have a higher cost share. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that the maximum allowance was exhausted while processing the claim.
Date of Service
Billed Amount
Allowed Amount
Difference
Plan Paid
Your Responsibility
1/13/2020
$270
$144
$126
$144
$0
1/20/2020
$410
$250
$160
$250
$0
10/9/2020
$1,010
$978
$ 32
$103
$875
11/25/2020
$200
$86
$114
$86
$114
12/16/2020
$1,876
$1,010
$866
$417
$1,459
TOTAL:
$1,000
$2,448
Therefore, we decided that the Plan does not have to waive the member liability for the oral exam (D0120), prophylaxis (D1110), the core build up (D2950), crown (D2750), and the filling (D2391) provided from November 25, 2020, to December 16, 2020.
Your complaint about being misled to believe the provider was in network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Sincerely,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on October 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says once a corrected claim is received, the claim can be reprocessed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The claim shows a Type of Bill (TOB) of 781. This is not valid for this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have 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 that the enrollee was admitted to the hospital due to difficulty breathing from COVID-19 infection. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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 Plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health certification services provided on September 2,
2020 by an out of network provider.
You asked the Plan to pay for physician or allowed practitioner certification for Medicare-covered home health
services (G0180). You say that the physician provided medically necessary services in good faith. The Plan
denied your request. The Plan says you did not request 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for home health certification services provided on September 2, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the daily replacement sensors provided on April 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the daily replacement sensors. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 daily replacement sensors provided on April 2, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the routine transportation services. You say that you would like
reconsideration because you were referred to a more qualified provider at the requested destination. The Plan
denied your request. The Plan says this trip exceeds 50 miles.
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 routine transportation when the one-way trip does not exceed 50 miles driving distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the record indicates
that this trip exceeds the 50-mile limit as outlined in your contract with the Plan. Therefore, we decided that the
Plan does not have to pre-approve routine transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the home ventilator. You say that the records provided support the need for
the requested item. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator. Our reviewer says
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is considered
not medically necessary. This enrollee has a diagnosis of COPD, although there are no pulmonary function
tests to confirm this. The enrollee was recently hospitalized with acute hypoxic and hypercarbic respiratory
failure and was successfully treated with BiPAP. The AVAPS mode of support that is ordered can be provided
by certain BiPAP devices, at less cost. Medicare does not cover a ventilator when used as BiPAP.
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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.
You asked the Plan to pre-approve additional miles. You say that you are unable to drive. The Plan denied your request. The Plan says your benefit only allows 50 miles.
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 file shows that transportation for over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers routine transportation for up to 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 additional mileage for routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Prolia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoporosis and has been taking oral alendronate. Progression of bone loss has been confirmed with bone density testing. While the documentation does support that the enrollee has tried and failed oral bisphosphonate medication, the records do not document trial and failure of intravenous zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the injection. You say that this should be reconsidered and approved. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this request is considered a standard of care. You previously had the same injection with good results. The request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 was admitted with sepsis from peritonitis. The enrollee has leukocytosis,
tachycardia, and a low hemoglobin. The enrollee is not clinically stable. The enrollee continues to receive acute
critical care services, and these have not been denied. The medical record does not indicate that the enrollee
requires services that they are not currently receiving but that would be available at the LTACH facility. The
elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.