Persius/hicric huggingface dataset:
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 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 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 shoulder pain and had arthroscopy of the shoulder. 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.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage represented by code A0425 provided on November 1, 2020.
You asked the Plan to pay for code A0425. 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 claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code A0425 is 250. You billed 258 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code A0425 have not been met.
Therefore, we decided that the Plan does not have to pay for the ground mileage represented by code A0425 provided on November 1, 2020.
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 based on the enrollee's current condition and functional deficits, as well as his multiple comorbidities he meets full inpatient acute rehab criteria based on both CMS and MCG guidelines. The Plan denied your request. The Plan says the clinical information does not support medical necessity for an acute rehabilitation stay.
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 there are no complex rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. The enrollee 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 enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy, 45 minutes with patient (CPT code 90834) provided on January 14, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 psychotherapy, 45 minutes with patient (CPT code
90834) provided on January 14, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleanings (D1110), comprehensive evaluation (D0150),
and complete series of intraoral x-rays (D0210) provided on September 30, 2020, and October 14, 2020.
You asked the Plan to pay for the dental services. You say that you did not know that this provider was out-ofnetwork
as you did not receive a booklet for in-network dentists. The Plan denied your request. The Plan says
this provider is out-of-network and your liability has been applied correctly. The Plan pays according to a
maximum allowable fee schedule and you are responsible for all fees in excess of this amount to the billed
amount. There is no record of you contacting the Plan to verify the provider's status or to find an in-network
provider, and an outreach to the provider confirmed that they inform all patients of their network status.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage.
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. The Plan pays for dental services according to a maximum allowable
fee schedule. If you choose to see an out-of-network dentist, you may be billed for any charges that exceed this
maximum fee up to the charges billed by the provider.
The record shows that the Plan has paid the full maximum allowable fee for each of the services provided, and
you are being asked to pay the remainder of the providers charges. 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 the
cleanings (D1110), comprehensive evaluation (D0150), and complete series of intraoral x-rays (D0210)
provided on September 30, 2020, and October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection procedure you had at an outpatient hospital facility on January 26, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you only had injections, so this shouldn't be considered surgery. The Plan denied your request. The Plan says the injection procedure is considered a surgical service, so you were charged this copayment 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 $250 copayment for surgery at an outpatient hospital facility. You have been asked to pay a $250 copayment for the outpatient surgery. Medicare considers facet joint injection procedures to be surgical services. 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 facet joint injection procedure you had at an outpatient hospital facility on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on March 3, 2021 by an OON provider.
You asked the Plan to pay more for periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis. You say that the booklet you received advised preventive and comprehensive dental services would be covered by the Plan up to $1,000.00 per year with no copayment. You also say that you would like these services paid in full, and the Plan materials corrected. The Plan denied your request. The Plan says the total liability amount of $154.00 was applied correctly. The Plan also says that member liability is a contractual obligation under the plan and cannot be waived.
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 for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on March 3, 2021 by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing (U0003) provided on November 5, 2020.
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the Covid-19 testing (U0003) provided on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Fortesta 10 mg/actuation gel.
You asked the Plan to pre-approve Fortesta gel. You say that the requested treatment is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Fortesta 10 mg/actuation gel.
Benefits for Fortesta gel may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physical therapy (PT) services you received from October 29, 2020, to December 18, 2020.

You asked the Plan to waive the coinsurance for the PT services. You say that you were told there would be no copayments through the end of the year because of the Coronavirus pandemic. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that their phone records confirm that you were advised cost sharing was only waived from May 11, 2020 through September 20, 2020. Because these services were after that date, the coinsurance applied.

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 15% coinsurance for physical therapy services.

You have been asked to pay 15% coinsurance for the PT services. 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 coinsurance for physical therapy (PT) services you received from October 29, 2020, to December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that this is needed to treat the enrollee's lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.
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 Vertiflex superion device placement surgery for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting; the LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured and the appropriate lower level of care can be determined.
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 that there is no documentation provided necessitating 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/she 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided to the enrollee on February 16, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the records indicate that the enrollee has been previously tested with NGS for a diagnosis of lung cancer (Omniseq and Guardant360), authorization of coverage cannot be provided, and the claim remains denied.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file show that the enrollee has been previously tested with NGS for a diagnosis of lung cancer through Omniseq and
Guardant Health. Per the NCD: NGS (90.2) criteria has not been met. Medicare Coverage is considered if you have not been previously tested with NGS for the same cancer. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided to the enrollee on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code 99214), duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT code 93925), and duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (CPT code 93970) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that the services are medically necessary. The Plan denied your request. The Plan says the medical notes indicate that this is not an emergency. The Plan states an emergency is a life-threatening condition that needs treatment within 24 hours and this service is available within the enrollee's network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code 99214), duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT code 93925), and duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (CPT code 93970) to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) and Pain assessment (G8730) provided on November 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 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 chiropractic manipulative treatment (98941) and Pain assessment (G8730) provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided on January 23, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you were under the impression that copayments for testing and treatment for COVID-19 were being waived. The Plan denied your request. The Plan says the COVID-19 cost-sharing waiver policy does not apply to ambulance services. This copayment was 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for the ambulance transportation services. 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 emergency ambulance transportation services (A0429, A0425) provided on January 23, 2021.