Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sciatic nerve injection rendered on August 13, 2019.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 code 64445 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 64445 is injection(s), anesthetic agent(s) and/or steroid; sciatic nerve.We find that CPT code 64445 is not supported in the medical record. Specifically, there is no documentation of a sciatic nerve injection. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the sciatic nerve injection rendered on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for you. The
Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above
criteria have been met.
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiographic/surgical implant index (D6190) and cone beam CT capture and interpretation (D0366) provided on March 10, 2020.
You asked the Plan to pay for the radiographic/surgical implant index and cone beam CT capture and interpretation. You say that these services were not for cosmetic reasons, but were for medical issues. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 radiographic/surgical implant index (D6190) and cone beam CT capture and interpretation (D0366) provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 17, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not
perform these services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the health plan sufficient information to determine whether payment is due and the
amount of payment.
We looked at the file and Medicare rules. The documentation submitted does not show that the lab services
were provided by the provider in question. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the
lab services provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit provided on February 3, 2020.
You asked the Plan to reduce the copayment for the podiatry visit. You say that your card says a specialist visit is $30. You say if podiatry services have a different copayment, it should be listed on the card. 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 $50 copayment for each Medicare-covered visit. You have been asked to pay a $50 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry 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 reduce the copayment for the podiatry visit provided on February 3, 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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records show that the enrollee has significant chest findings and has not competed the full course in the 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. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two home health LPN visits for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is now medically stable after 33 previous skilled nursing visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 services. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the enrollee has had multiple skilled nursing visits since March 2020. On 6/17/20, it is documented that the enrollee had shortness of breath with minimal exertion or agitation. She requires BG testing every morning. Additional skilled nursing visits were requested for disease process management, medication compliance and regimen, and pain management. The plan approved 3 additional skilled nursing visits. The documentation does not support that the 2 additional home health skilled nursing visits are required to effectively provide treatment, care, and/or services for the enrollee in this case.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 not been met.Therefore, we decided that the Plan does not have to pre-approve two home health LPN visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee replacement provided on December 2, 2019.
You asked the Plan to waive the coinsurance for the knee replacement. You say that all authorizations were completed prior to surgery. You say that you were not informed of any out-of-pocket costs. The Plan denied your request. The Plan says the coinsurance 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 50% of the total cost per out-of-network stay. You have been asked to pay $8,162.31, which is 50% of the allowed amount for the knee replacement. The allowed amount is $16,324.61 (50% x $16,324.61 = $8,162.31). The knee replacement falls within the "Inpatient hospital care" 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 coinsurance for the knee replacement provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 18, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services provided by non-participating providers are not covered under the enrollee's Plan unless they are authorized by the Plan before the services are provided.
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 physician's services provided on November 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on March 21, 2020.You asked the Plan to waive the copayment forthe ambulance ride. You say that you have never had to pay for ambulance rides when you are taken to the hospital.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rulessay 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 $150 copayment for Medicare-covered ground ambulance services (one-way). You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 forthe ambulance ride provided on March 21, 2020.Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee meets acute inpatient rehabilitation admission criteria under Medicare guidelines. The Plan denied your request. The Plan says based on Medicare guidelines, IRF services do not meet the requirements for approval.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 that 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. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from January 9, 2020 to January 26, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be liable for the cost share due to the high cost. 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 $300 copayment per day for days 1-5 and a $0 copayment per day for additional days for in-network Medicare-covered inpatient hospital stays. You have been asked to pay a $300 copayment for each day, for days 1 to 5 of your inpatient hospital stay. ($300 x 5 = $1,500). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from January 9, 2020 to January 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upholstered portion of the seat lift chair. You asked the Plan to pre-approve the upholstered portion of a seat lift chair. You say that you need a seat lift chair. The Plan denied your request. The Plan says the lift chair base is a non-Medicare item. The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. Medicare only covers the seat lift mechanism. Based on this information, we decided that Medicare rules for coverage of the upholstered portion of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve the upholstered portion of the seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for provision of test materials and equipment for home INR monitoring provided from February 7, 2020 to February 21, 2020. You asked the Plan to pay for provision of test materials and equipment for home INR monitoring. You say that the Plan should pay for the three weeks of supplies. The Plan denied your request. The Plan says you have 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 and units. We find that CPT code G0249 was billed for three separate units of weekly service. Based on this information, we decided that Medicare rules for coverage of provision of test materials and equipment for home INR monitoring have not been met. Therefore, we decided that the Plan does not have to pay for provision of test materials and equipment for home INR monitoring provided from February 7, 2020 to February 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical history of hypertension, coronary artery disease, hyperlipidemia, past pulmonary embolus and chronic systolic congestive heart failure who presented to the acute hospital on 06/06/2020 with a fall and acute back pain with a lumbar vertebral compression fracture. She was treated in hospital with a kyphoplasty as well as gabapentin, Lidoderm and oxycodone. She is working with physical and occupational therapy. She is walking 200 feet with a rolling walker with supervision/contact guard assistance and she is supervision/contact guard assist for transfers and activities of daily living. She is medically stable. The provided medical records do not indicate a need for skilled nursing services. The provided medical records do indicate a need for skilled therapy services. The provided medical records do not indicate a need for daily skilled services. The provided medical records do not indicate a need for inpatient services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection services.
You asked the Plan to pre-approve injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested injections are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar injections are only covered for certain 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 injections. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee has both chronic neck pain and low back pain. The enrollee had imaging and Physical therapy, Pool Therapy and a Home exercise program in 2017. There are no recent physical therapy notes or imaging submitted. The enrollee does not meet the criteria of LCD with no recent imaging of the lumbar spine and no recent conservative therapy with physical therapy, Chiropractic or other physical medicine methods.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injection services.