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 the services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital 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 you are currently undergoing treatment at an acute care hospital (ACH) following
emergency surgery for a cecal volvulus. You are not intubated/ventilated. There is no evidence that you require
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no
acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing
long term care (LTC) needs.
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 drug testing services 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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to 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 drug testing services provided to the enrollee on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee has been receiving cardiac care with the provider since 2017. The Plan denied your request. The Plan says there are multiple par providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 25, 2020 through February 26, 2020. You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says code 99284 billed without an appropriate modifier.
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Specifically, the record indicates that multiple evaluation and management services were billed on this claim. CPT code 99284 has been billed without modifier 25 to indicate that this is a significant, separately identifiable evaluation and management service. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on February 25, 2020 through February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the low-level laser treatment (S8948) provided June 28, 2019 to August 2, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) and the low-level laser treatment (S8948) provided June 28, 2019 to August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete series x-rays (D0210) provided February 20, 2020.
You asked the Plan to pay for the dental x-rays. You say that you were referred to this provider but they was not able to fully diagnose your condition with the existing x-ray files, therefore the provider requested a more detailed x-ray to come up with a treatment plan. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.
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. This service is covered once every 3 years. Records show that this service was provided November 7, 2019. 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 complete series x-rays (D0210) provided February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 31, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that emergency bills have always been paid. You say that the bill should be taken care of.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 $230 copayment per one-way trip for Medicare-covered ground ambulance services. You have been asked to pay a $230 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 the ambulance transport provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee requires the head of the bed to be at least 30 degrees and is unable to weight shift. The Plan denied your request. The Plan says the record is inconsistent on elevation of head of bed to the enrollee's condition and no evidence that the enrollee cannot change position in bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found the documentation is inconsistent, between the vendor prescription form and the inpatient rehabilitation patient assessment, that the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed, frequent or immediate changes in body position. The enrollee's condition does not require special attachments that cannot be fixed and used on an ordinary bed. The enrollee does not meet the requirements for a semi-electric bed (E0261) per Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve new complete mandibular dentures.
You asked the Plan to pre-approve the dentures. You say that a new denture is needed because of cancer.
The Plan denied your request. The Plan says this is not covered by Medicare, and there is no supplemental
plan benefit for the requested dental services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve new complete
mandibular dentures.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance  imaging (MRI). You asked the Plan to pre-approve an MRI. You say that this should be covered.The Plan denied your request. The Plan says records were not submitted to show this is necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. No medical records pertaining to this request have been submitted. Without this information, medical necessity cannot be established. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance  imaging (MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid purchased on December 11, 2019 from a non-participating provider.
You asked the Plan to pay for the hearing aid. You say that the claim should be paid. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor'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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Review of the file show that you purchased the hearing aid from a non-participating provider. There is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor's network. Your EOC states, you must see a participating hearing aid vendor provider to use this benefit. 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 hearing aid purchased on December 11, 2019 from a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that The Plan does not have to pre-approve a skin graft procedure (15275, Q4133)
You asked The Plan to pre-approve skin graft procedure. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says the requested skin graft is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the skin graft. Our reviewer says that
the requested procedure is not medically necessary at this time. Our physician reviewer found that it appears
that effective conservative treatment is still most appropriate at this time. Diabetes needs to be better controlled
and circulation improved first to ensure graft success and long-term benefit.
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 skin graft have not been met.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve the requested injection. The Plan denied your request. The Plan says the enrollee's pain or function has not improved by at least 50% after the last injection.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications. 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 requested injection. Our physician reviewer found that the enrollee has a diagnosis of chronic low back pain and lumbar radiculopathy. In December 2019, the enrollee underwent an epidural steroid injection. Submitted office notes state that the enrollee had some improvement. Epidural Injections are considered not medically reasonable and necessary if a prior epidural injection procedure provided limited or no relief. Therefore, based upon the submitted documentation it is not medically necessary and reasonable for this enrollee to have a second epidural steroid injection. 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 requested injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) and intraoral - periapical first x-ray (D0220) provided January 8, 2020.
You asked the Plan to pay for the dental services. You say that you had an abscess and could not get amoxicillin without seeing a dentist. You will not be getting any exams because you can't afford to have any work done. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 limited oral exam (D0140) and intraoral - periapical first x-ray (D0220) provided January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 85025, 80061, and 36415 provided on October 1, 2019. You asked the Plan to pay for the laboratory 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. We find that CPT codes 80053, 85025, 80061, and 36415 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records (signed and dated by the ordering physician). Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 85025, 80061, and 36415 provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99219) provided on January 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the surgery payment.
The Plan must follow Medicare rules. Medicare rules say that evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment. We looked at the file and Medicare rules. The documentation provided does not show that the enrollee was seen for a full E&M visit on the date of the surgery, and is no evidence that there was an E&M visit which led to the initial decision to perform surgery. 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 99219) provided on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing provided on December 15, 2019.
You asked the Plan to pay for lab test. You say that you only perform this test in your hospital laboratory. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include any medical records of this test or a physician order for this testing. The Plan requested this information, but it was not submitted. Therefore, you have no furnished sufficient information to the Plan to justify coverage of this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent disease testing provided on December 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says there has not been an
inadequate response to six weeks of conservative treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our physician reviewer found
that the enrollee has primary osteoarthritis of the right knee. The enrollee has had knee pain for four weeks.
The pain is rated at 4-5/10. The treatment plan includes considering the use of a knee brace, steroid injection of
the right knee and starting visco-supplementation. An x-ray of the knee showed advanced arthritis of the lateral
compartment and patellofemoral joint. There is no documentation that the enrollee has had an inadequate
response or contraindication to conservative treatment such as physical therapy, a trial of non-steroidal antiinflammatories,
or further workup. Therefore, the requested services are not medically reasonable and
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 Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC). 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.