Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate hip replacement surgery.
You asked the Plan to pre-approve the immediate surgery. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee has no fractures or infection that require immediate attention or
surgery.
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 the immediate surgery. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee presents with right hip pain. Functional limitations have been noted in
mobility. Clinical exam findings are generally consistent with radiographic evidence of severe right hip
degenerative joint disease. He has failed to improve with activity modification and a greater trochanteric bursa
injection. He has been recommended for elective right total hip arthroplasty. Records indicate that elective
surgery has been approved, but surgical scheduling has been delayed due to COVID-19. Under consideration is
a request from the enrollee for immediate hip replacement surgery. There is no indication for urgent/immediate
surgery in this enrollee's right hip osteoarthritis. There is no evidence that additional conservative treatment
could not be utilized to assist in symptom management while the enrollee awaits elective surgery scheduling.
The request for right total hip replacement is medically necessary, but the enrollee does not require immediate
surgery based on the available medical records.
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 immediate surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve immediate hip replacement surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12 & 15.You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the service is not medically necessary.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. The Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the crowns of tooth #'s12 & 15 do not meet the Plan's coverage criteria. Our physician reviewer found there is no apparent damage to the structure of either tooth #12 or tooth #15 that require restoration. It is also noted there is at least 50% loss of bone support on #12 and #15, making the periodontal status questionable in the long term. Our physician reviewer also found that given the lack of any notable damage to the either tooth that would necessitate restoration, as well as the noted compromised periodontal condition of both teeth, there is no necessity for crowns on either teeth #12 or #15. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met.Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12 & 15.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing provided on March 16, 2020.
You asked the Plan to pay for infectious agent disease testing. You say that you only perform this testing in your hospital laboratory. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this testing is not covered by Medicare for this diagnosis.
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 infectious agent disease testing. Our reviewer says that this test does not meet the Medicare criteria for coverage. Our physician reviewer found this testing was not medically reasonable or 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 infectious agent disease testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent disease testing provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99201) provided on March 5, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99201) provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) ankle foot orthosis (L1971)
and shoulder elbow wrist hand orthosis (L3960) provided January 30, 2020.
You asked the Plan to pay for the orthoses. You say that the records sent earlier was the relevant records to
services rendered and it contained all the detailed info about the services. Please review and process the claim
accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and
management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines. L0650 exceeds the DME reasonable useful lifetime.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis
(L0650) ankle foot orthosis (L1971) and shoulder elbow wrist hand orthosis (L3960) provided January 30,
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 are appealing based on medical necessity. 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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require IRF level of therapies and your rehabilitation needs can be met at a lower intensity setting such as skilled nursing facility. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 8, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for X-Ray exam. You say that prior authorization is not required for this service.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and no valid referral was obtained for this service.
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 the medical services provided on November 8,
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 87633) provided on March 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCA A57579 provides a list of non-covered codes. We looked at the file and Medicare rules. Per A57579, CPT code 87633 is a non-covered code. 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 87633) provided on March 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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
drug testing services provided on May 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation
provided on January 10, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis, bitewings, and periodic oral evaluation. You say that this
treating provider assumed the practice of your previous dentist, who was in-network. You also say that you
were not notified that this provider had changed to an out-of-network status. The Plan denied your request. The
Plan says the treating provider is OON with your plan. The Plan also says that no benefits are available for
procedures performed by OON providers or outside of the providers contracted period.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
prophylaxis, bitewings, and periodic oral evaluation provided on January 10, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on February 24,
2020.
You asked the Plan to waive the copayment for lab services. You say that the charges should be included in
your dialysis treatment and 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 $30
copayment for lab services.
You have been asked to pay the allowed amount of $4.74, which is less than the $30 copayment for lab
services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 lab services provided on February 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for immunohistochemistry services (CPT 88341) provided to the enrollee on December 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the submitted medical records do not support the units billed; therefore, the billed service cannot be verified.
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 88341 is "Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)." 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 reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found there is documentation provided that specifically supports the CPT codes in question, and the units billed. 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 been met. Therefore, we decided that the Plan has to pay for immunohistochemistry services (CPT 88341) provided to the enrollee on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a mammogram (77067, 77063) provided
January 16, 2020.
You asked the Plan to waive the coinsurance for the mammogram. You say that the screening mammogram
should be covered in full. The Plan denied your request. The Plan says there is a coinsurance applied when a
screening mammogram is received out-of-network.
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 50%
coinsurance for screening mammograms provided out-of-network.
You have been asked to pay a 50% coinsurance for the mammogram that was provided by an out-of-network
provider. 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 a mammogram (77067, 77063) provided
January 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation services (G0378)
provided February 17, 2020 to February 18, 2020.
You asked the Plan to waive the copayment for the observation services. You say that the hospital visit was
caused by a reaction to a drug you were given following a surgical procedure and therefore the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was 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 a $395
copayment for Outpatient Hospital Observation.
You have been asked to pay a $395 copayment for the observation services. The observation services fall
within the Outpatient Hospital Observation 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 hospital observation services (G0378) provided February 17, 2020 to February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 6, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 27, 2020 through February 29, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found this is a patient with unknown baseline pulmonary function who presents with a documented infiltrate and hypoxemia. This combination clearly makes it reasonable to assume that this patient is suitable for admission and is at risk for acute decompensation. Presumably patient has underlying lung disease that has worsened. It was reasonable and appropriate at the time of admission to believe the patient would need to stay two (2) or more 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 27, 2020 through February 29, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq tablets.
You asked the Plan to pre-approve Rinvoq tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Rinvoq tablets are not covered under the enrollee's Medicare Part B benefit.
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 Rinvoq tablets.
Benefits for Rinvoq tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergy injection provided on April 29, 2020.
You asked the Plan to waive the copayment for the allergy injection. You say that you have not been charged a copayment for allergy shots prior to 2020. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the allergy injection.
You have been asked to pay a $8.98 copayment for the allergy injection. The allergy injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the allergy injection is considered a physician service.
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 allergy injection provided on April 29, 2020.