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 the LTACH does not provide a clinical advantage over a non-LTACH acute care 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 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 26, 2020.
You asked the Plan to pay for the dental service. You say that as people get older, dental coverage should be increased. You say that you cannot afford to pay for your dental exam out of pocket. The Plan denied your request. The Plan says prophylaxis is covered twice per plan year. The Plan also says that the frequency limit has been exceeded.
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 frequency limit of 2 prophylaxis per calendar year has been exceeded. The record shows that the Plan paid for prophylaxis that you received on February 20, 2020, and June 22, 2020. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 11, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 genetic testing is not supported in the medical record. Specifically, these services should be billed with 81479. In addition, the approved DEX Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on October 22, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation intraoral periapical x-rays, and bitewing x-rays. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says that you did not elect to purchase an optional supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization, endovascular, open or percutaneous, iliac artery (37222) provided September 18, 2020.
You asked the Plan to pay for the surgical services. You say that you are requesting a reconsideration for additional payment for services rendered. Enclosed please find necessary documentation to review. The Plan denied your request. The Plan says the service is not supported in the medical records submitted.
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 37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure). We find that CPT code 37222 is not supported in the medical record. Specifically, the operative report did not include documentation of revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure). Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for revascularization, endovascular, open or percutaneous, iliac artery (37222) provided September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exams and cleanings provided from March 11, 2020, to November 2, 2020.
You asked the Plan to pay for the dental services. You say that you were advised the services should be covered because they are preventive in nature. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services rendered by a non-contracting dentist are not covered under your 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 oral exams and cleanings provided from March 11, 2020, to November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on October 7, 2020.
You asked the Plan to waive the copayment for the surgery. You say that you were not aware that there would be a copayment because you thought it was a preventive service. The Plan denied your request. The Plan says this was a diagnostic colonoscopy not preventive.
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 show that you received the diagnostic colonoscopy provided on October 7, 2020. The indication for colonoscopy was due to a positive Cologuard test; therefore, this was not a preventive colonoscopy. You are asked to pay a $350 copayment for the diagnostic colonoscopy. Your 2020 EOC states enrollees must pay a $350 copayment for surgery at an Outpatient Hospital Facility. 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 colonoscopy provided on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 22, 2020, to June 18, 2020.
You asked the Plan to pay for the skilled nursing services. You say that you are an out-of-network provider and no additional credentialing needs to be done. The Plan denied your request. The Plan says the provider does not have a valid Medicare CCN on file. The Plan also says that the treating provider is not a PPS exempt provider and the termination date of October 18, 2018 reflects the last date the provider was serviced by the outgoing MAC.
The Plan must follow Medicare rules. Medicare rules say that if the provider is terminated or transferred to another MAC, a termination date is placed in the file to reflect the last date the provider was serviced by the outgoing MAC. Likewise, if the provider identification number changes, the MAC must place a termination date in the file for the old provider identification number. We looked at the file and Medicare rules. Review of the PSF file entry for CCN 335238 shows that there is a termination date of October 18, 2018, meaning this was the last day the reporting MAC serviced the provider under this number. There is also an unexplained discrepancy in the file, since the FY begin date is after the effective date. Per the rules in Addendum A, this is not valid. Resolution of these discrepancies must be done between the MAC and the provider. The Plan does not have any control over this data. As the data appears to show that the CCN provided is not currently valid, we find that the rules for payment of the SNF care at issue have not been met. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 22, 2020, to June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the complete series x-ray (D0210) provided on October 28, 2020.
You asked the Plan to pay the in-network rate for the complete series x-ray. You say that this provider was listed on the Plan's provider directory as in network as of January 20, 2020. You say that you do not want to be charged the extra amount of money. You also say that you went to the dentist address that was on the provider directory that was given to you. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate for the complete series x-ray (D0210) provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopic services coded 43281 provided on February 10, 2020.
You asked the Plan to pay for the laparoscopic 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 not supported by the documentation.
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 43281 is laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh. The CPT Code Manual definition of code 49999 is unlisted procedure, abdomen, peritoneum and omentum. We find that CPT code 43281 is not supported in the medical record. Specifically, the operative report did not include documentation of surgical laparoscopic repair of a paraesophageal hernia including fundoplasty when performed; without implantation of mesh; therefore, code 43281 cannot be verified. The unlisted procedure of the abdomen, peritoneum and omentum is documented in the operative note submitted for review; however, this procedure is considered inclusive to CPT code 43775-80, a surgical laparoscopic, gastric restrictive procedure; longitudinal gastrectomy (sleeve gastrectomy); therefore this code
cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the laparoscopic services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopic services coded 43281 provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 23, 2020, through April 28, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient hospital care provided was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 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 enrollee presented to the emergency room (ER) for the evaluation of chest pain. The enrollee was found to be COVID positive but was asymptomatic. The enrollee was also found to be anemic and was given iron. She was admitted to telemetry and evaluated by Cardiology. Acute coronary syndrome was ruled out. She was stable throughout the days in the hospital. She was then discharged back to the skilled nursing facility when considered medically stable on April 28, 2020. The review has determined that the record did not show that at the time of the inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 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 the 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 April 23, 2020, through April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable gaseous oxygen system (E0431) and oxygen concentrator (E1390).
You asked the Plan to pre-approve the portable gaseous oxygen system and oxygen concentrator. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 portable gaseous oxygen system and oxygen concentrator. Our reviewer says that the request for home supplemental oxygen does not meet Medicare criteria. Our physician reviewer found the medical records do not include data that would support a need for supplemental oxygen, such as pulse oximetry less than 89% while breathing room air, either at rest or with exercise. Supplemental oxygen is therefore considered 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 portable gaseous oxygen system and oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable gaseous oxygen system (E0431) and oxygen concentrator (E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 11, 2020, through October 14, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that this was an emergency room event and you should not have to pay this amount. 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 $275 copayment per day, days 1 to 7 at an in-network inpatient hospital. You have been asked to pay an $825 copayment for the inpatient stay. ($275/day x 3 days = $825). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were admitted as an inpatient. 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 inpatient stay provided from October 11, 2020, through October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Exemestane for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Exemestane for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, panoramic x-ray, first intraoral periapical x-ray, and extraction provided on June 19, 2020, and June 23, 2020.
You asked the Plan to pay for the bitewings, panoramic x-ray, first intraoral periapical x-ray, and extraction. You say that x-rays are covered once per year, and extractions are also covered. The Plan denied your request. The Plan says your 2020 calendar year maximum has been met.
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 Plan offers a $1,500 combined allowance for supplemental preventive and comprehensive services every year. The contract clearly states that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing the claim for the June 19, 2020 date of service, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings, panoramic x-ray, first intraoral periapical x-ray, and extraction provided on June 19, 2020, and June 23, 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 you need acute rehabilitation and can tolerate 3 hours of therapy daily. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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.