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

We decided that the Plan does not have to pay for lab services provided on December 11, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab services. You say that the member has no control where the lab gets sent.
You say that you would like this claim reprocessed and approved for payment. The Plan denied your request.
The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did
not refer these services.
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 lab services provided on December 11, 2019 by an
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on July 18, 2019.You asked the Plan to pay forthe laboratory testing. Yousay that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exceptionof the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on July 18, 2019.
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 your needs can be met at a lower 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a heavy duty wheelchair (K0006).
You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met by a cane or walker.
The Plan follows Medicare rules. Medicare rules say that a wheelchair is covered when the beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. 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 wheelchair. Our reviewer says that the wheelchair is not medically necessary. Our physician reviewer found the documentation does not support that the patient is unable to complete her activities of daily living in the home due to a mobility deficit, that she is unable to ameliorate a mobility deficit with a walker or manual wheelchair, or evidence that she can safely operate the wheelchair in the home. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a heavy duty wheelchair (K0006).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482)
provided to the enrollee on October 22, 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 according to the claims data available at the time of the review, the plan was unable to discover
any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
HCPCS G0482:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia,
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g.,
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed
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 reviewer says that the
services at issue in this case were not supported by the records. Our physician reviewer found based on the
medical records provided, the documentation does not support the coding of CPT 80307 and HCPCS G0482.
The records do not show evidence of an established relationship between the enrollee and the ordering
physician.
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 pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on October 22,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 9, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, electroencephalography, and diagnostic testing services provided on April 16, 2019.
You asked the Plan to pay for the office visit, electroencephalography, and diagnostic testing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the office visit, electroencephalography, and diagnostic testing services was not filed until April 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit, electroencephalography, and diagnostic testing services provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on February 25, 2020.You asked the Plan to waive the copayment for eye exam. You say that you went in for your annual routine eye exam, so it should have had a $0 copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $40 copayment for diagnostic eye exam. This exam included a non-routine diagnosis; therefore, it is considered to be a diagnostic examination and not a routine examination.You have been asked to pay $40 copayment for eye exam. Eye exam falls within the Vision 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 an eye examination provided on February 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission.. You say that you would like reconsideration because
the member requires daily physical therapy, occupational therapy and skilled nursing. The Plan denied your
request. The Plan says the member's objective evidence of function shows that this member required custodial
care assistance with his activities of daily living.
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 SNF admission.. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF admission. have not been met. Therefore, we decided that the Plan
does not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. There is concern that this enrollee has a deep vein thrombosis (DVT) but she refuses testing. Additionally, her hemoglobin has dropped despite transfusion and is not at baseline and she has rales noted on her lung exam which was not present on preoperative progress notes. She does not appear medically optimized to transfer to a rehabilitation facility from the submitted documentation. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergen immunotherapy injection
provided on February 27, 2020.
You asked the Plan to waive the copayment for the allergen immunotherapy injection. You say that you were
told there would be no copayment for the services. 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 allergen immunotherapy injection.
You have been asked to pay a $10.36 copayment for the allergen immunotherapy injection. The allergen
immunotherapy injection falls within the "Physician/Practitioner services, including doctor's office visits"
benefit category. The record shows the allergen immunotherapy 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 allergen immunotherapy injection provided on February
27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation.
You asked the Plan to pre-approve these services. You say that you need the procedure. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific
criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have chest pain. There is no documentation that you are having pain that limits your mobility or activity due to
venous reflux. The veins in question are relatively small. Most importantly, you have no documentation of
peripheral pulses. The records do not support that endovenous ablation is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve endovenous ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for mandibular partial denture -cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on February 26, 2020.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay for mandibular partial denture -cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total hip arthroplasty.
You asked the Plan to pre-approve total hip arthroplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that total hip arthroplasty is 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 total hip arthroplasty. Our reviewer says that the documentation does not support that the requested total hip arthroplasty is medically reasonable or necessary. Our physician reviewer found the enrollee presents with a history of bilateral hip osteonecrosis. There is imaging evidence of bilateral hip bone-on-bone deformity with periarticular osteophyte formation, subchondral sclerosis, and collapse of the femoral heads bilaterally consistent with osteonecrosis. There is a history of failed conservative treatment. Under consideration is a request for total hip arthroplasty. The submitted medical records are from 2018 and do not evidence a current pain or functional assessment, interval surgical/non-surgical treatment history, or clear documentation of the planned surgery relative to laterality. At this time, there is insufficient evidence that this enrollee has a diagnosis, condition and/or symptoms that fully meet the Medicare criteria for coverage of total hip arthroplasty. Therefore, it is not currently medically reasonable and necessary for this enrollee to have total hip arthroplasty as requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total hip arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve total hip arthroplasty.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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 enrollee was admitted to acute care on 6/23/2020 at a smaller community hospital with shortness of breath and weakness. The enrollee was transferred to a larger hospital on 6/24/2020 and treated for fluid overload and a urinary tract infection. The enrollee discharged on 7/2/2020 and re-admitted on 7/8/2020 with recurrent massive fluid overload with pulmonary edema and tense 4+ peripheral edema. The enrollee is scheduled to have an arteriovenous fistula placed on 7/24/2020. He is being treated with hemodialysis and intravenous antibiotics. He is weak and deconditioned and is being evaluated by physical and occupational therapy. He is not able to walk and is dependent for transfers and activities of daily living. He has ongoing issues with need for vascular access for dialysis and lower extremity cellulitis. He does not appear medically stable. The enrollee does have complex medical issues but he presently does not appear to be stable to transfer to an acute rehabilitation facility. The enrollee does require physical therapy and occupational therapy services but
based on the medical records provided the enrollee does not appear stable for transfer at this time. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Further care in the acute hospital 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 acute inpatient rehabilitation facility (IRF) admission and services.