Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use (code D9630) and bone replacement graft for ridge preservation (code D7953) provided on May 29, 2019.
You asked the Plan to pay for the drugs or medicaments and bone replacement graft. You say that this provider did surgery that other dentists would not do. You also say that they did your dentures and should be paid. The Plan denied your request. The Plan says these services are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use (code D9630) and bone replacement graft for ridge preservation (code D7953) provided on May 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 11, 2019 through August 13, 2019, by an out-of-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you were admitted to the emergency room with the inability to choose what providers service you. You state the claim should be processed in-network due to these circumstances.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019EOC 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 to an out-of-network provider on August 11, 2019 and discharged on August 13, 2019. You were asked to pay a $325 copayment per day from August 11, 2019 through August 12, 2019, days 1-2 of your inpatient hospital care. You were discharged on August 13, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5 for in-network inpatient hospital care. Therefore, your claim was processed with your in-network benefits. 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 inpatient hospital care provided from August 11, 2019 through August 13, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 26, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 for imaging services provided to the enrollee on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 18, 2019 to August 19, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the treatment and appropriate care for the enrollee presenting with an asthma exacerbation and chest pain could not have been performed in an outpatient setting. The Plan denied your request. The Plan says the services could have been managed safely in an outpatient setting after evaluation and treatment in the emergency department and did not require an acute admission.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 that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.
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 provided from August 18, 2019 to August 19, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 3, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services. 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 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 medical services provided to the enrollee by an out-of-network provider on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on July 2, 2019 by the out of network provider. You asked the Plan to pay forpathology services. You say that you would like this claim paid.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 for pathology services provided on July 2, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity (73218).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the enrollee presented with a mass on his arm. No other history or physical examination was provided. There was no documentation from a face to face visit. Insufficient records were provided to support the need for an MRI. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity (73218).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cervical posterior decompression with fusion for the enrollee.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the notes need to show failed injections at the level recommended for the fusion.
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 pay for the services. Our reviewer says that the
services at issue in this case are not medically reasonable or necessary. Our physician reviewer found the
records do not show any evidence of cervical instability. There is no neurologic deficit or severe stenosis.
Criteria for surgery is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for cervical posterior decompression with fusion for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CTA of the abdomen (74175).
You asked the Plan to pre-approve a CTA of the abdomen (74175). You say that the requested CTA of the abdomen is medically necessary. The Plan denied your request. The Plan says the requested CTA of the abdomen 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 a CTA of the abdomen (74175). Our reviewer says that the requested CTA of the abdomen is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension and hyperlipidemia. The enrollee presented with episodic epigastric discomfort associated with pressure sensation arising to head associated with rise in systolic blood pressure. She had been referred for workup for angina with nuclear stress testing. She was also referred for non-contrast CT of abdomen and pelvis and 24 hour urine collection. She was apparently now referred for CT angiography of abdomen as well and the health plan has denied this as not medically reasonable and necessary in this clinical situation. The enrollee has risk factors for coronary artery disease and a symptom complex which could be consistent with cardiac ischemia. She was appropriately referred for cardiac ischemia testing. Given the abdominal complaints as well, non-contrast CT of abdomen and pelvis is also reasonable. There is apparently some concern for possible pheochromocytoma given the symptom complex and hypertension, though this is not mentioned in the body of the notes provided, however a 24 hour urinary VMA/catecholamines was ordered. There are no results of this urinary testing provided either. If this biochemical testing were positive, then CTA or MRI of the abdomen would then be appropriate to assess for a pheochromoctyoma. However, in the absence of biochemical abnormalities associated with a pheochromcytoma tumor, radiologic studies like CTA or MRI are not indicated based on current guidelines for the diagnosis of this condition. If the urinary studies were to suggest an abnormality, then the CTA would be indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA of the abdomen (74175) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CTA of the abdomen (74175).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested
admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested
admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility
(SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the
enrollee is with a diagnosis of acute sigmoid diverticulitis being treated with IV antibiotics and bowel rest. She
also has right hip pain from a fall. The enrollee's prior level of function is limited ambulating with rolling
walker or used wheelchair for mobility. On 2/1/20 she was tolerating regular diet, on oral Augmentin. Her
kidney disease was stable and she was on home blood pressure medications. She had some hospital delirium.
On 2/4/20 the enrollee was ambulating with contact guard assistance for 31 feet with walker and minimal assist
to stand from chair.
This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a
skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment only
in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF
level skilled nursing need. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide
medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled
nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter
this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we
decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that your spouse is unable to take care of you at home. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on August 15, 2019.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you have never paid for a mammogram before. You say that you don't think you have to pay this bill. 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 $100 copayment for diagnostic procedures and tests at an in-network outpatient hospital facility. You have been asked to pay a $100 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the mammogram was performed to evaluate abnormal results, which is considered diagnostic. 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 diagnostic mammogram provided on August 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rezum procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Rezum procedure is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lower urinary tract symptoms that include frequency, decreased force of urinary stream and voiding twice each night. He has been treated with tamsulosin and finasteride for over three years. His most recent prostate specific antigen (PSA) level was 0.33 ng/mL on November 27, 2018. A cystostocpy on December 9, 2019 revealed a non-obstructing prostate. His International Prostate Symptom Score (IPSS) was not greater than or equal to 13, the maximum urinary flow rate was not less than 15 mL/s, and the prostate volume was not 30 to 80 cc. The enrollee does not meet the criteria for coverage of the Rezum procedure and it is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Rezum procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on October 16, 2019.
You asked the Plan to waive the copayment for a cataract surgery. You say that the procedure was postoperative
and you disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $175
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You have been asked to pay a $175 copayment for a cataract surgery. A cataract surgery falls within the
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical
centers 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 a cataract surgery provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99397) provided on June 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE is exceeded for this code.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee Schedule indicates that the code in question is not covered by Medicare. We looked at the file and Medicare rules. Procedure code 99397 is assigned a status indicator of "N" under the Physician Fee Schedule, which means that this code is not covered by Medicare. 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 (CPT 99397) provided on June 11, 2019.