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

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued IV antibiotics. The Plan denied your request. The Plan says the services can be safely provided in the current acute care setting.

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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted for gallbladder surgery. The enrollee's post-operative course was complicated by development of a hernia and duodenal leak necessitating additional surgery. The enrollee is currently receiving antibiotics, bowel rest and parenteral nutrition. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lidocaine injection provided to the enrollee on August 16, 2019.You asked the Plan to pay for the injection. You say that this should be paid for.The Plan denied your request. The Plan says the correct HCPCS code for lidocaine injection is J3490; therefore, the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS code J2001 is: injection, lidocaine HCl for intravenous infusion. We asked our coding 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 injection. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found HCPCS code J2001 is not supported by the medical record. The record does not state the route of administration for the lidocaine. It cannot be verified that the lidocaine was administered as an intravenous infusion.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plan does not have to pay forlidocaine injection provided to the enrollee on August16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement auto adjusting continuous positive airway pressure device with humidifier.You asked the Plan to pre-approvea replacement ACPAP with humidifier. You say that your current ACPAP is failing, you need a new one, and you have a prescription.The Plandenied your request. The Plan says your current ACPAP has not been assessed for repairs.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have aACPAP with humidifier received in 2016. This ACPAP is still under reasonable useful lifetime and there has been no assessment of the working condition of this ACPAP to see if it can be repaired. ThisACPAP with humidifier received in 2016 serves the same purpose as a replacement ACPAP with humidifier.Therefore, we decided that the Plan does not have to pre-approvea replacement auto adjusting continuouspositive airway pressure device with humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).You asked the Plan to pre-approvethe dental item. You say that you are experiencing pain in your teeth and jaw. You say that the pain is causing migraines and grinding.The Plan denied your request. The Plan says occlusal guards are 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, an occlusal guard is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean occlusal guard (D9944).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment fora nuclear bone imaging scan provided by "the hospital" on October 3, 2019.You asked the Plan to waive the deductible and copayment forbone imaging scan. You say that this scan was ordered by your primary care doctor and should be fully covered.The Plan denied your request. The Plan says the cost-sharing amounts you are beingcharged are correct.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 $300 deductibleand $150 copayment for in-network bone imaging scan. At the time this claim was processed, $19.25 of the $300 in-network deductible amount had been met. The allowed amount of this claim is $334.38, resulting in a deductible amount of $280.75, which meets the $300 total in-network deductible for 2019. After the deductible is met the remaining allowed amount of the claim is $53.63, however you have only been asked to pay $20 copayment which is less than the applicable $150 copayment and less than the remaining amount of the claim. Your total cost-sharing obligation is therefore $300.75.You have been asked to pay $300 deductible and less than $150 copayment for bone imaging scan. bone imaging scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 deductible and copayment fora nuclear bone imaging scan provided by "the hospital" on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve surgical removal of erupted teeth and alveoplasty.You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or servicesare not among those covered under this benefit. The request is for extractions on 19 different teeth. A review of the file shows that two extractions were already approved on January 24, 2020. The remaining 19 extractions cannot be covered. Additionally, alveoplasty is not listed as a covered service in your contract.Therefore, we decided that the Plandoes not haveto pre-approvesurgical removal of erupted teeth and alveoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from February 18, 2019 through March 13, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).Review of the file shows that you were admitted on February 18, 2019 and discharged on March 13, 2019. You were asked to pay a $475 copayment per day from February 18, 2019 through February 20, 2019, days 1-3 of your inpatient stay. There were no copayment charges from February 21, 2019, day 4 of your inpatient hospital care until your day of discharge March 13, 2019. Per your contract there is a $475 copayment per day required for days 1-3. 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 forinpatient hospital care provided from February 18, 2019 through March 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visits provided on January 12, 2018 and February 7, 2018.You asked the Plan to pay for office visits. You say that these claims were filed in a timely manner and you are requesting payment.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the claim for these visits was not submitted within the timely filing limits. The Plan also says that they have approved payment for the remaining visits from March 8, 2018 to December 18, 2018, so this denial is only fordates of service January 12, 2018 and February 7, 2018.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 a claim for office visits was not filed until February 16, 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 foroffice visits provided on January 12, 2018 and February 7, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decidedthat the Plan does not have to pre-approve4 extractions (D7210) for denture placement, by an oral surgeon, to be covered under your medical benefit.You asked the Plan to pre-approvethe dental services. You say that you are aware that the extractions are covered under your dental plan. You say that you cannot afford to pay your cost share of 75% of the specialist fee. You say that you need the extractions to be covered under the medical outpatient benefit so you can afford it.The Plan denied your request. The Plan says that extractions for denture placement are not covered under your medical benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by your medical benefit.Therefore, we decided that the Plan does not have to pre-approve4 extractions (D7210) for denture placement, by an oral surgeon, to be covered under your medical benefit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on October 3, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the submitted records do not support the billing of codes 95940, 95955, 95908, 95885, and 95999.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 95940 is continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure). The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done withnerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95999 is 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 these services. Our reviewer says that the submitted records do not support the billing of codes 95940, 95955, 95908,95885, and 95999. Our physician reviewer found code 95955 is not supported in the records. This code applies to an EEG during surgery exclusive of surgery to the brain. This description was not documented in the medical record, therefore, the service cannot be verified and it is inappropriate to submit CPT codd 95955 for reimbursement consideration for services provided on October 30, 2018. The description of codes 95908, 95886, and 95999 are not documented in the medical record, therefore it is inappropriate to bill these codes for reimbursement consideration.
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 pay forthe services rendered on October 3, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveensure nutritional supplements (B4150).You asked the Plan to pre-approvethe nutritional supplements. You say that you have lost more than 10 pounds since the supply was stopped in April when you got out of hospice and you are not able to consume solid food and need to get nutrition from ensure.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveensure nutritional supplements (B4150).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services during cystourethroscopy services provided on February 7, 2019.You asked the Plan to pay forthe assistant surgeon services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 52000. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services during cystourethroscopy services provided on February 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve15 additional skilled nursing home health visits.You asked the Plan to pre-approve15 additional skilled nursing home health visits. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare criteria have not been met.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 15 additional skilled nursing home health visits. Our reviewer says that the enrollee does not meet criteria for coverage of additional home health skilled nursing visits. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. There are no documented complex 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 15 additional skilled nursing home health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve15 additional skilled nursing home health visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 10 physical therapy visits.You asked the Plan to pay forthe 10 physical therapy visits. You say that the physical therapy visits are medically necessary. The Plan denied your request. The Plan says the physical therapy visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 10 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee's prior therapy did not show objective change in lower extremity strength and showed no change in lumbar range of motion.Our reviewer found the requested 10 physical therapy visits would be considered excessive for his condition and that theenrolleeshould be able to transition to an independent home exercise 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 the 10 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pay forthe 10 physical therapy visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pontic and retainer crown provided on August 15, 2019.You asked the Plan to pay forthe pontic and retainer crown. You say that this was three crowns. You say that you should be reimbursed since the bridge was not repairable.The Plan denied your request. The Plan says these are not covered benefits.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.The Plan offers a dental benefit in excess of Medicare coverage. The pontic and retainer crown are considered a partial denture, which isnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe pontic and retainer crown provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics provided on August 6, 2019.You asked the Plan to pay forthe ambulatory surgical boot (L3260). You say that the Plan should pay this claim.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 followsthese same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay forfoot orthotics provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 9, 2019to October 28, 2019.You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.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 proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 9, 2019 to October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from May 7, 2019 toJuly 26, 2019.You asked the Plan to pay forthe diabetic supplies. The Plan denied your request. The Plan says that there was no valid proof of delivery submitted.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 proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from May 7, 2019 to July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).