Persius/hicric huggingface dataset:
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 you would like reconsideration because LTACH admission is medically necessary. The Plan denied your request. The Plan says the member's care may be safely provided in a different setting.
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 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve the additional ten (10) PT visits. The Plan denied your request. The Plan
says the additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional ten (10) PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee should
be able to transition to a home exercise program and continue work with his personal trainer as he currently is
doing. The requested services are not part of a maintenance program, are the specialized skill, knowledge and
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.
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 additional ten (10) PT visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee brace (L1852) and a miscellaneous durable medical equipment supply (A9900) provided on August 29, 2020.
You asked the Plan to pay for a knee brace and a miscellaneous supply. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not indicate that it corresponds to the items at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a left knee brace (L1852) and a miscellaneous durable medical equipment supply (A9900) provided on August 29, 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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is not stable for transfer to an LTACH.
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 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. 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 Guardant360 testing (81120, 81121, 81173, 81201, 81235, 81270, 81272, 81275, 81310, 81311, 81314, 81321) provided on September 17, 2020.
You asked the Plan to pay for Guardant360 testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT 81479 is used to report Guardant360 testing. We find that CPT codes 81120, 81121, 81173, 81201, 81235, 81270, 81272, 81275, 81310, 81311, 81314, and 81321 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81235, 81270, 81272, 81275, 81310, 81311, 81314, 81321) provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) received December 23, 2020.

You asked the Plan to pay for the implant supported porcelain/ceramic crown. You say that you cannot afford the cost of the service. The Plan denied your request. The Plan says the requested service is not covered under your 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 implant supported porcelain/ceramic crown (D6065).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (93308) provided on July 21, 2020.
You asked the Plan to pay for echocardiography. You say that this is documented in the records. The Plan denied your request. The Plan says this code 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 93308 is echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study. We find that CPT code 93308 is not supported in the medical record. Specifically, the submitted medical records do not include image documentation for the billed date of service. Based on this information, we decided that Medicare rules for coverage of echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for echocardiography (93308) provided on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on October 15, 2020.
You asked the Plan to pay for the PET scan. 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 78815 is positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. We find that CPT code 78815 is not supported in the medical record. Specifically, this PET scan claim was not billed with an appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2020 by a non-participating provider.
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 the services were rendered by a non-participating provider without prior authorization.
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 the laboratory services provided on November 9, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies rendered on September 10, 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 codes S1015 and S8301 are not supported.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing kit) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies rendered on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the non-autogenous connective tissue graft procedure, each additional tooth, (D4285 x 5), and the non-autogenous connective tissue graft, first tooth, (D4275 x 2) provided on November 13, 2020.
You asked the Plan to reimburse you for the non-autogenous connective tissue graft procedures. You say that these services were for surgery. You say that it was performed on multiple teeth at the same time. You say that in the denial, it was indicated that the insurance would cover this treatment one time for every 2 teeth that are next to each other. You say that you were following the advice of your dentist. You say that you feel this should be covered under your medical plan. You also say that The Plan denied your request. The Plan says services in connection with teeth and supporting structures are not covered by Medicare. The Plan says the services you received are not listed as covered under the Dental Rider either. The Plan also says that dental services that are not listed are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the non-autogenous connective tissue graft procedure, each additional tooth, (D4285 x 5), and the non-autogenous connective tissue graft, first tooth, (D4275 x 2) provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided
December 8, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that this device was
medically necessary for the enrollee. The Plan denied your request. The Plan says the documentation submitted
did not sufficiently document the member's medical condition.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. In this case, although the provider has indicated that the criteria for the therapeutic continuous
glucose monitor have been met, no medical records were provided which corroborate this claim. The record
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore,
we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided
December 8, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity weakness and sepsis and was treated for a flare of multiple sclerosis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect.
You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this
testing is medically necessary. The Plan denied your request. The Plan says this service is not a Medicare
covered test.
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for the
CxBladder assay.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CxBladder Detect have not been met. Specifically, this is not a Medicare covered test.
Therefore, we decided that the Plan does not have to pay for CxBladder Detect.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on November 6, 2020.
You asked the Plan to reduce the copayment for the intravitreal injection of a pharmacologic agent. You say that there should only be a specialist copayment. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees must pay $270 copayment for Outpatient Surgery. The enrollee has been asked to pay $270 copayment for the intravitreal injection of a pharmacologic agent. The intravitreal injection of a pharmacologic agent falls within the Outpatient Surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on November 6, 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2392) provided on November 9, 2020.
You asked the Plan to pay for the dental service. You say that you have had 4 heart attacks. You say that your dentist recommended you have the crack in your tooth fixed for preventive purposes. You say that you were not in any pain at that time. You also say that clerical person contacted your plan and advised they would pay like $300 per year. The Plan denied your request. The Plan says the filling is not a covered service. The Plan says that the filling is not a preventive 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 filling is not among those covered under this benefit. The record shows that you contacted the Plan prior to the date of service and were advised of the services that are considered preventive dental services. Fillings are not a routine or preventive dental service. Therefore, we decided that the Plan does not have to pay for the filling (D2392) provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and preventive procedure provided on December 3, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and preventive procedure. You say that you were advised that getting up to two teeth pulled would be covered at 50%. The Plan denied your request. The Plan says these services are not covered.
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 and preventive procedure provided on December 3, 2020.