Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided on November 18, 2019, to June 2, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient mental health services. You say that this provider has helped tremendously. You say that you were unable to find an in-network provider who can provide this level of care.The Plan denied your request. The Plan says there are in-network providers available. The Plan says that prior authorization was not 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services provided on November 18, 2019, to June 2, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and diarrhea associated with COVID 19 infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing orrehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 anIRF.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-approveacute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on January 2, 2020.
You asked the Plan to waive the copayment for the duplex scan. The Plan denied your request. The Plan says the copayment 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures. You have been asked to pay a $155 copayment for the duplex scan. The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The duplex scan is an aortic ultrasound, which is considered a diagnostic radiology service. 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 duplex scan provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. 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 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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of servicesprovided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kit transit securement package (CPT Code K0108).
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request.
The Plan says this is not covered by Medicare. The Plan must follow Medicare rules. The rules say that for
equipment to be covered, it must primarily serve a medical purpose. Medicare guidance says that equipment
used for non-medical purposes or outside the home is not covered. This includes a kit for use on public transit
or in a car. This is because it is for convenience. Medicare says "durable medical equipment" for wheelchairs
must be reasonable and necessary, or it can't be covered. The item at issue in this appeal does not serve a
purpose that is primarily medical in nature. This item is available to the general public and would be helpful
even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve kit
transit securement package (CPT Code K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe porcelain onlay (D2643) provided on September 3, 2020.You asked the Plan to reimburse you forthe dental service. You say that you were led to believe that the $965 that you paid wasfor the temporary crown that you received on the date of service in this case and for the permanent crown that you will receive at the end of the month. You say that you wer not given a choice as to which care plan you wanted.The Plan denied your request. The Plan says onlays are not listed as a covered service. The Plan says that you were notified prior to receiving the service that you would be responsible for the onlay.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 reimburse you forthe porcelain onlay (D2643) provided on September 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 22, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that you believe that you need additional time in the SNF due to your condition. The Plan denied your request. The Plan says you no longer require daily skilled therapy to maintain your functional status and are not likely to improve further with continued daily therapy.
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 continued SNF car. Our reviewer says that daily skilled services are not necessary.
Our physician reviewer found the enrollee was admitted to SNF on 12/1/2020 after a surgical fixation of a femur fracture. He began the stay requiring maximal assist for sitting up or lying down. As of 12/20/2020, he was requiring moderate assist for bed mobility and maximal assist for transfers. He reportedly refused to ambulate. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee has reached a plateau in function and is noted to be at his baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 the continued SNF car have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 22, 2020.
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 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for syncope and fall after a recent (resolved) COVID 19 infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ursodiol 300mg capsules.
You asked the Plan to pre-approve the ursodiol capsules. You say that the enrollee has been stable on this medication and should not be forced to stop a drug that is working well. The Plan denied your request. The Plan says this is a self-administered drug that is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ursodiol 300mg capsules.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe interrogation device evaluations provided on January 3, 2020.You asked the Plan to pay forinterrogation device evaluations (93295, 93296). You say that your device has to be monitored.The Plan denied your request. The Plan says a claim was paid for date of service February 9, 2020 so this claim cannot be paid as it was within 90 days.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare only pays for this service every 90 days. Based on this information, we decided that Medicare rules for coverage of the duplex scans have not been met.Therefore, we decided that the Plan does not have to pay forthe interrogation device evaluations provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral exam (D0150), bitewing radiographic images (X-Ray) (D0274) and standard cleaning (D1110) provided on July 27, 2020.
You asked the Plan to pay for a comprehensive exam, bitewing X-rays and standard cleaning. You say that the service should be covered. The Plan denied your request. The Plan says the member liability was correctly applied.
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. For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. 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. Specifically, you received your services from an out-of-network provider. The total charges by the out-of-network provider exceed the MAC payment made by the plan. This means you are liable for the difference between the amount the provider charged and the amount the MAC allows. Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam (D0150), bitewing radiographic images (X-Ray) (D0274) and standard cleaning (D1110) provided on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not documenta need for an intensive rehabilitation program. 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.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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal puncture services coded 62270, the initial hospital
care services coded 99223, and the electroencephalogram (EEG) services coded 95816 provided on November
20, 2019.
You asked the Plan to pay for the spinal puncture services, the initial hospital care services, and the
electroencephalogram (EEG) 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 a duplicate to services already processed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 62270, 99223, and 95816 are not supported in the medical record. Specifically, the
services coded 62270 and 99223 were already previously processed under claim 820193580197564. In
addition, code 95816 was included in code 62270. In addition, we have confirmed that code 95816 has a
bundled relationship with code 62270 and cannot be paid as billed. This code cannot be paid as a separate line
item. Based on this information, we decided that Medicare rules for coverage of the spinal puncture services,
the initial hospital care services, and the electroencephalogram (EEG) services have not been met. Therefore,
we decided that the Plan does not have to pay for the spinal puncture services coded 62270, the initial hospital
care services coded 99223, and the electroencephalogram (EEG) services coded 95816 provided on November
20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on August 3, 2020.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction was billed for a medical condition and is not covered by your Plan. Eye refractions are only covered when billed as a routine eye exam.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. We looked at the file and the Plan's rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on
August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compounded drugs with CPT code J3490 provided on May 12, 2020.You asked thePlan to pay forCPT code J3490. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered 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.We find that CPT code J3490 is not supported in the medical record. Specifically, the records indicate that drug in compounding form was administered. There is a more appropriate CPT code, J7999, that should be used to bill for drugs that are administered in compound form. Based on this information, we decided that Medicare rules for coverage of CPT code J3490 have not been met.Therefore, we decided that the Plan does not have to pay forthe compounded drugs with CPT code J3490 provided on May 12, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea breath analysis.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this test is being requested for small bowel bacterial overgrowth and CO2.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea breath analysis