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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient 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 physician reviewer found the documentation indicates that there is no indication for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 2, 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. The Plan denied your request. The Plan says you do not require
aggressive therapies by an intensive team to properly regain function.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you were admitted to the acute care hospital for Covid-19. Your medical conditions are stable. There are
no complex nursing needs. You do not require treatment by multiple therapies, including either physical or
occupational therapy, in an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Partially Favorable

You asked the Plan to waive the coinsurance for parenteral nutrition supplies. You say that you believe the Plan saved money by not having to pay for a 2-week long skilled nursing facility stay which would have been dangerous to your life, so you are requesting a more reasonable payment amount due to the circumstances at the time. The Plan says that the cost-sharing amounts you are being charged are correct.

We decided that the Plan has to reduce the coinsurance for parenteral nutrition supplies.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay 20% coinsurance for parenteral nutrition supplies. Here is a summary of the appropriate cost-sharing amounts for these claims:

The Plan says you must pay $1,078.06 for parenteral nutrition supplies. Based on the Plan contract, however, you cannot be asked to pay more than $984.02, which is 20% coinsurance for parenteral nutrition supplies. Therefore, we decided that the Plan has to reduce the coinsurance for parenteral nutrition supplies from $1,078.06 to $984.02.

We also decided that the Plan does not have to waive the coinsurance for parenteral nutrition supplies.

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 parenteral nutrition supplies. The allowed amounts of these claims total $4,920.04, resulting in a total coinsurance amount of $984.02. Therefore, we decided that the Plan does not have to waive the coinsurance for parenteral nutrition supplies.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and periodontal
maintenance provided on February 1, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and periodontal maintenance. You say
that you should not be held responsible for the difference because you were not advised that this provider is
OON. The Plan denied your request. The Plan says these services were rendered by an OON provider.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and periodontal maintenance provided on February 1, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 28, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, coverage is denied when a laboratory assays two or more genes in an enrollee in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
November 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided July 22, 2020.
You asked the Plan to pay for the office visit. You say that you should be fully reimbursed for the service. The Plan denied your request. The Plan says the claim was processed at the Medicare allowable amount. The enrollee was already reimbursed except for their cost-share.
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 $30 copayment for Office Visits. You have been asked to pay a $30 copayment for the office visit. 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 pay for an office visit (99213) provided July 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 19, 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 97167 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 97167 is Occupational therapy evaluation, high complexity, typical time with patient 60 minutes. We find that CPT code 97167 is not supported in the medical record. Specifically, the records show that the services were performed in a home setting and there is a more appropriate code for these services. 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 for the occupational therapy services rendered on September 19, 2020.
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 still has numerous medical
conditions requiring a doctor's attention. The Plan denied your request. The Plan says the enrollee has not
completed his full course in the acute 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 physician
reviewer found that the enrollee presented with acute respiratory failure, secondary to a congestive heart failure
exacerbation. The enrollee is receiving appropriate care at the present acute care hospital. He does not require
services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 pay for the vascular ultrasound guidance (76937) provided on
December 1, 2020.

You asked the Plan to pay for the vascular ultrasound guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been reported with an appropriate primary procedure code.

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, we have confirmed that code the vascular ultrasound guidance is a Type II add-on code and cannot be paid as billed. A Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment This code cannot be paid as a separate line item. The record shows that CPT code 76973 has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the vascular ultrasound guidance (76937) provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the enrollee on January 7, 2021.
You asked the Plan to pay for PET imaging provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met, as the diagnosis code used on the claim is not supported by the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis and service codes that report the service billed to the highest degree of specificity. The claim itself was billed with a diagnosis code of "C50.919 defined as Malignant neoplasm of unspecified site of unspecified female breast". However, the medical records provided indicate the right breast was the part of the body that was the area of concern.
In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body than the right breast required imaging, the claim should have reflected that with the appropriate codes being billed and submission of the appropriate medical record documentation. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the enrollee on January 7, 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.
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 enrollee can be treated at a lower level of 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 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. Our physician reviewer found the enrollee does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy procedures provided on July 29, 2020.
You asked the Plan to pay for the laparoscopy, surgical; proctopexy (for prolapse) (45400) and laparoscopy, surgical, colpopexy (57425). You say that an assistant at surgery was necessary. The Plan denied your request. The Plan says the services were performed by a Surgical Technologist/Surgical First Assistant.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy procedures provided on July 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound behind the abdominal cavity provided on January 13, 2021.
You asked the Plan to waive the copayment for the ultrasound behind the abdominal cavity. You say that this was an abdominal aortic aneurysm screening and should be 100% covered. The Plan denied your request. The Plan says you have been asked to pay 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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $160 copayment for the ultrasound behind the abdominal cavity. The ultrasound behind the abdominal cavity falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the ultrasound behind the abdominal cavity was performed in addition to the abdominal aortic aneurysm screening. 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 ultrasound behind the abdominal cavity provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 vaccine provided on February 26, 2021.

You asked the Plan to pay for the COVID-19 vaccine. You say that you were not told you had to use your Medicare card at the pharmacy. The Plan denied your request. The Plan says claims for the COVID vaccine must be submitted to Original Medicare.

Original Medicare pays for the COVID-19 vaccine. The Plan follows the same rules. 

Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine provided on February 26, 2021. However, records show the pharmacy billed Original Medicare and the claim was paid.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 144 additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need transportation to dialysis appointments Mondays, Wednesdays, and Fridays. The Plan denied your request. The Plan says your request exceeds the benefit allowance for routine transportation trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. The records show that the Plan has
covered 40 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 144 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for photochromatic tint (V2744) and polycarbonate coating (V2784) for eyeglasses purchased on February 26, 2021.
You asked the Plan to pay for the lens enhancements. You say that you disagree with this denial. The Plan denied your request. The Plan says the lens enhancements are not covered by your supplemental vision benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Plan's contract does not offer an additional provision for coverage of lens enhancements with routine eyewear. Based on this information, we decided that the Plan's rules for coverage of the lens enhancements have not been met. Therefore, we decided that the Plan does not have to pay for photochromatic tint (V2744) and polycarbonate coating (V2784) for eyeglasses purchased on February 26, 2021.