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 clinical documentation provided supports the need for LTACH care.The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place of an acute care hospital.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 physicianreviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on May 9, 2019.
You asked the Plan to pay for the dental services. You say that the payment of only $76 by the Plan is an error. You say that the coverage you have entails you to more payment than is reflected on the Explanation of Dental Plan Reimbursement. The Plan denied your request. The Plan says the dentist in this case is an out of network provider. The Plan says there is a $100 deductible for services that you receive out of network. The Plan also says you pay 50% coinsurance for dental services that you receive out of network.
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 dental services that you received out of network are subject to a $100 deductible in addition to the 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on May 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that additional therapy is medically necessary and the IRF level of care is appropriate. The Plan denied your request. The Plan says the enrollee's needs can be met safely at a lower level of care. The Plan says that the clinical information does not show that the enrollee meets the guidelines for coverage of IRF care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on October 1, 2019.
You asked the Plan to pay for the dental service. You say that you were not informed that the provider only took supplemental. The Plan denied your request. The Plan says the comprehensive periodontal evaluation is not listed as a covered service.
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 dental services you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total parenteral nutrition for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says if the prescribing physician would have prescribed for 3 months or more, this would meet the criteria. However, one week does not imply permanent or semi-permanent needs.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation does not support that the enrollee has permanent, severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the beneficiary's general condition. There is no documentation that the enrollee has a condition that is expected to last at least 3 months. There is no condition that impairs the ability of nutrients to be transported through the GI system. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve total parenteral nutrition for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary. The Plan denied your request. The Plan says the member does not meet the guidelines for SNF services.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in an 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam received August 26, 2019.
You asked the Plan to waive the copayment for a medical eye exam. You say that you had a routine eye exam and there should be no copayment. The Plan denied your request. The Plan says this was a medical (diagnostic) eye exam.
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 $45 copayment for each Medicare-covered exam to treat an eye condition. You have been asked to pay a $45 copayment for a medical eye exam. The record shows that your provider provided and billed for a medical eye exam. This was due to your condition of age-related cataract, disorders of refraction and accommodation and keratitis. 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 a medical eye exam received August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 27, 2019.
You asked the Plan to pay for the dental service. You say that the service was medically necessary to treat your gum disease. You say that the dentist has a plan for you to have quarterly checks and cleanings. The Plan denied your request. The Plan says the frequency limit has been exceeded.
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 cleanings are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for cleanings you received on January 30, 2019 and May 22, 2019. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a root canal (D3347) provided on October 2, 2019.
You asked the Plan to pay for the dental service. You say that you spoke to a Plan representative on the phone prior to receiving the service. You also say that you were advised that the service would be covered. The Plan denied your request. The Plan says the service you received is not a covered service.
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 dental service you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of a root canal (D3347) provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a need for a rehab doctor 3 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a reasonable and predicted period. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit.
You asked the Plan to waive the copayment for an emergency room visit. You say that the doctor didn't do anything and didn't care about your pain. The Plan denied your request. The Plan says the correct copayment has 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 for an emergency room visit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had a right shoulder replacement on February 4, 2020 and right pneumothorax. She had stable vital signs and was effectively treated for pain. She received physical and occupational therapy in the hospital and needs assistance with functional mobility, including walking 100 feet with a rolling walker. She is non-weight bearing to the right arm. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 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-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room provided on October 27, 2019.
You asked the Plan to waive the copayment for the emergency room. You say that you were not informed when you enrolled in the plan that you could have called your doctor for emergency care. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $120 copayment for emergency services at an in-network emergency room. You have been asked to pay a $120 copayment for the emergency room. The emergency room 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 for the emergency room provided on October 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture with a flexible base (D5225).

You asked the Plan to pre-approve the upper partial denture. The Plan denied your request. The Plan says a partial denture with a flexible base is not listed as a covered service.

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, partial denture with a flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture with a flexible base (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging services and an office visit (99204, 74230, 72040, 70100, 70310, 70360 and 74240) provided January 2, 2019.
You asked the Plan to pay for diagnostic imaging services. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says we find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier 26 by the interpreting physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare guidance says A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. We find that CPT codes billed are not supported for payment. Specifically, the TC of radiology services are not separately payable in this case. The services were billed globally, but payment for physicians radiological services to the hospital is made by the AB MAC to the hospital as a provider service. The office visit code is not appropriate for an enrollee in a skilled nursing facility. Based on this information, we decided that Medicare rules for coverage of diagnostic imaging services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic imaging services and an office visit (99204, 74230, 72040, 70100, 70310, 70360 and 74240) provided January 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a basic metabolic panel (80048) provided September 26, 2019.
You asked the Plan to pay for a basic metabolic panel. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services are non-covered screenings.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a basic metabolic panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a basic metabolic panel (80048) provided September 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you received a bill for the services provided on March 13, 2017. You asked the Plan to look into it. The Plan denied your request. The Plan says these services are not a covered benefit.
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 13, 2017. 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 services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery.
You asked the Plan to pre-approve the oral surgery. You say that this surgery is medically necessary as you are in pain and unable to eat or speak. The Plan denied your request. The Plan says this procedure is not on the covered list for dental procedures or oral surgery that are covered under the medical plan.
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 pre-approve oral surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886-RT 95886-LT) provided May 2, 2019.
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that the billed services were medically necessary. The Plan denied your request. The Plan says the billed services 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. We asked our coder 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 nerve conduction studies and needle electromyography. Our reviewer says that codes 95911, 95886 RT and 95886 LT are not supported by the medical records. Our coder reviewer found the medical records provided do not include documentation of nerve conduction studies; 9-10 studies, therefore, the service cannot be verified. The documentation supports 8 studies, which does not meet the definition criteria of CPT code 95911. CPT code 95886 is an add-on code, which requires its primary code to be eligible for reimbursement on the same date of service the add-on code is performed. Primary CPT code 95911 was denied on the same claim for the same date of service, therefore, CPT code 96886 is not eligible for reimbursement. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886-RT 95886-LT) provided May 2, 2019.