Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transport -
basic life support (A0428) and ground mileage, per statute mile (A0425) provided March 25, 2021.

You asked the Plan to waive the copayment for the non-emergency ambulance transport and ground mileage.
You say that you require ambulance transportation and it should be covered. The Plan denied your request. The
Plan says the copayment has been applied correctly.

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 $290
copayment for non-emergency ambulance services.

You have been asked to pay a $290 copayment for the non-emergency ambulance transport and ground
mileage. This service falls within the Ambulance 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 non-emergency ambulance
transport - basic life support (A0428) and ground mileage, per statute mile (A0425) provided March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found you are medically stable and have been provided medical clearance to undergo this
elective procedure.

The planned procedure is not listed on the CMS Inpatient Only List and is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
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 an LTACH would more appropriately meet your current medical needs. If you are discharged or released to a skilled nursing facility, you will most likely be readmitted to the hospital. The Plan denied your request. The Plan says the criteria for admission to an LTACH have not been met. The records indicate that you have not completed the full course of care in the hospital. An LTACH would not provide a clinical advantage over a non-LTACH acute care hospital, and therefore, this request cannot be approved.

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 you are receiving continued acute care services, and these have not been denied. The medical record does not indicate that you require services that you 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided March 12, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the injection was given by a nurse and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied based on the records.

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 $40 copayment for office visits. 

You have been asked to pay a $40 copayment for the office visit. the office visit falls within the office visits 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 office visit (99214) provided March 12, 2021.
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 enrollee is best suited for long term acute care. The Plan denied your request. The Plan says the records do not show the enrollee can breathe safely on his own.

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 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 he is 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on February 8, 2021.

You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you were not aware that the service would not be covered. You told the provider to only do services that would be covered. The Plan denied your request. The Plan says the service at issue is 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 6, 2021.

You asked the Plan to pay for the dental services. You say that the extraction was required for your surgery. The Plan denied your request. The Plan says plan benefits have 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.

The file shows that an unspecified oral surgery procedure (D7999) was provided. Although the Plan offers a dental benefit in excess of Medicare coverage, this service is not among those covered under this benefit.

The file also shows that extractions were provided and partially paid for. We looked at the file and Medicare rules. There is an annual maximum of $1000. The file shows that you reached the $1000 annual maximum with the services that were provided.

Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay for the dental services provided on January 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on April 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". 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 services. Our reviewer says that the use of code 97110 is not supported by the records provided. Our coding reviewer found that the medical records document that the service was performed in a home health or hospice service, therefore, code 97110 is not the most appropriate code to be billed for this service. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97110) provided on April 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet joint ablation 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 the benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that two radiofrequency ablation procedures are covered per calendar year. 

The file shows that the same procedure was last received in the same region on January 4, 2021 on January 18, 2021. 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 a repeat facet joint ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and endodontic therapy (D3330) provided on April 15, 2021.

You asked the Plan to pay for the crown (D2740) and endodontic therapy (D3330). You say that the literature prior to signing up says you are covered for up to $500 per year for comprehensive and preventive dental services. You say that the balance of $500 should be paid. The Plan denied your request. The Plan says the services 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and endodontic therapy (D3330) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided April 13, 2021.

You asked the Plan to pay for the limited oral exam. You say that this service should have been covered under your plan. The Plan denied your request. The Plan says the service exceeds the frequency limitation in your dental 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. The Plan covers the limited oral exam once per plan year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on March 29, 2021. Based on this information, we determined that the Plan's frequency limit for the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided April 13, 2021.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and cellulitis. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the joint injection services provided on February 3, 2021.

You asked the Plan to waive the cost share for the services provided. You say that you were never aware of the cost. The Plan denied your request. The Plan says the cost share is your responsibility.

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 $275 copay for services provided at an outpatient hospital for outpatient surgery. 

The file shows that you received a joint injection on the date of service at issue. The service is considered a surgical service. You have been asked to pay $250.34 for the services provided. Because the amount is less than the $275 copay, you were charged the lesser amount. The services fall within the outpatient 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 cost share for the joint injection services provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Grafix treatment provided from March 18, 2021, to March 25, 2021.

You asked the Plan to pay for the Grafix treatment. 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 pay for the Grafix treatment. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that multiple studies, including double-blind placebo-controlled studies, on diabetic foot ulcerations demonstrate efficacy of this skin substitute over placebo. The studies do advise that strict wound debridement and offloading of the ulcerative area are also necessary for effectiveness of this application. In this particular case, it is noted that the enrollee underwent medical stabilization and debridement of her ulceration to the right foot in January of 2021. Two months later, it was noted that the ulcerations did not progress or heal, and the decision to utilize Grafix applications was made. The Grafix skin substitute applications meet the medically necessary and reasonable guidelines for this 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 the Grafix treatment have been met. Therefore, we decided that the Plan has to pay for the Grafix treatment provided from March 18, 2021, to March 25, 2021. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to refund the copayment for the lumbar-sacral orthosis purchased on April 7, 2021.

You asked the Plan to refund the copayment for the lumbar-sacral orthosis. You say that you want your money back since you returned the orthosis. The Plan denied your request. The Plan says you were told by the supplier there would be no returns allowed for the orthosis.

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 20% coinsurance for Prosthetic Devices and related supplies. 

You have been asked to pay 20% coinsurance for the lumbar-sacral orthosis. The lumbar-sacral orthosis falls within the Prosthetic Devices and related supplies. 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 refund the copayment for the lumbar-sacral orthosis purchased on April 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 25, 2021.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for molar tooth (D3330) and
treatment of root canal obstruction (D3331).

You asked the Plan to pre-approve endodontic therapy for molar tooth and treatment of root canal obstruction.
You say that this request is medically necessary. The Plan denied your request. The Plan says these services are
not covered under the Plan's supplemental 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy for molar tooth (D3330) and treatment of root canal obstruction (D3331).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the private duty nursing rendered on September 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code T1000 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code T1000 (private duty nursing) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the private duty nursing rendered on September 22, 2020.