Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on January
19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the services were denied for noncoverage
however per a phone call with a representative, there are still out of network benefits. The Plan
denied your request. The Plan says non-emergent services with non-contracted providers require prior
authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you must obtain prior authorization for Outpatient mental health care. You can find this information on page 124 of the Plan's 2021 Evidence of Coverage. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on January 19, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140 x 7) and the surgical extractions (D7210 x 3) provided from January 12, 2021.
You asked the Plan to pay for the extractions. You say that you were advised that you could go to any dentist of your choice. You say that you could not find a dentist that would accept your insurance. You say that your dentist suggested you send a copy of the bill to your insurance. You also say that you have not received any checks for this claim. The Plan denied your request. The Plan says extractions have a 50% coinsurance. The Plan says that the provider in this case is out of network. The Plan also says that you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider.
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 and extractions are listed as covered, there is a 50% coinsurance that applies. Additionally, when services are performed out of network, you may be billed for any amount greater than the MAC payment made by the plan to the provider. This is a contractual obligation under the plan and cannot be waived.
CPT Code
Billed Amount
Allowed Amount
Difference
Coinsurance
Plan Paid
Your Responsibility
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7210
$263.20
$126
$137.20
50%
$63
$200.20
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7210
$263.20
$126
$137.20
50%
$63
$200.20
D7140
$158.40
$65
$93.40
50%
$32.50
$125.90
D7210
$263.20
$126
$137.20
50%
$63
$200.20
TOTAL:
$416.50
$1,481.90
Therefore, we decided that the Plan does not have to pay for the simple extractions (D7140 x 7) and the surgical extractions (D7210 x 3) provided from January 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 10, 2020, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith that the provider would be reimbursed. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 10, 2020, by an out-of-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 17, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that evidence-based guidelines do not support this testing for the enrollee's condition. Due to this, the Guardant360 testing is not medically 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on October 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a preloaded injector to deliver two anterior segment aqueous drainage service.
You asked the Plan to pre-approve insertion of a preloaded injector to deliver two anterior segment aqueous drainage service. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that glaucoma surgical aqueous drainage devices will be considered medically reasonable and necessary when approved by the FDA and used within accordance of the FDA-approved/cleared 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 insertion of a preloaded injector to deliver two anterior segment aqueous drainage service. Our reviewer says that the services are not medically necessary. Our physician reviewer found the available documentation does not support that the enrollee in this case is currently being treated with an ocular hypotensive medication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a preloaded injector to deliver two anterior segment aqueous drainage service have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a preloaded injector to deliver two anterior segment aqueous drainage service
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support the need for an inpatient admission. The Plan denied your request. The Plan says that the notes provided do not show why the enrollee needs to be inpatient. The Plan says that an inpatient level of care 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 pre-approve an inpatient hospital admission. Our reviewer says that the documentation supports that the criteria for an inpatient hospital admission are met in this case. Our physician reviewer found the record shows that at the time of the request for an inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. The enrollee was being treated for unilateral primary osteoarthritis of left knee. She is noted to have been approved for a left knee arthroplasty surgery. She is noted to have had increased potassium, BUN, and creatinine on pre-operative labs. EKG shows sinus rhythm with possible left atrial enlargement, along with right bundle branch block. A phone call was placed to primary care physician for them to review EKG prior to surgery. There is also additional significant history including essential hypertension, obstructive sleep apnea, Alzheimer's dementia, depression, and hypercholesteremia. The noted medical history along with findings on pre-operative testing support the need for an inpatient hospitalization of at least two midnights post-operative. This would be in order to closely monitor the enrollee as she is at increased risk for potential complications post-operative. Therefore, the request for inpatient hospital admission for scheduled knee arthroplasty is 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 an inpatient hospital admission have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
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: 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 need inpatient rehab to be able to go back to your way of life before your injury. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture
after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found
that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: 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 records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for weakness, urinary tract infection and Clostridium difficile colitis. The enrollee's
medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there
is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in
a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on March 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing provided on March 18, 2021 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429HH, A0425HH) received March 22, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan should cover the cost of the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $275 copayment for Ambulance Services. You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0429HH, A0425HH) received March 22, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Kidney imaging morphology (78708)
technetium tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries (A9562) provided February 17,
2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you were at the facility for
this same service on February 10, 2021 and should not be responsible for another copay. The Plan denied your
request. The Plan says the claim was processed with the correct copayment applied per the Evidence of
Coverage.
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 $75
copay per visit for Medicare covered diagnostic radiology services such as MRI CT and PET scans.
You have been asked to pay $75 copay per visit for the diagnostic service. the diagnostic service falls 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 Kidney imaging morphology (78708) technetium tc-99m mertiatide, diagnostic, per
study dose, up to 15 millicuries (A9562) provided February 17, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness
for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT
code E2313), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says Medicare guidance says that the upgraded electronics (expandable controller, harness
and electronic connector to 2 power options) are not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The notes state that these are needed
when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two
or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although
there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a
medical need to control these power options through the joystick. Upper limb strength and function are
adequate for the enrollee to be able to control the power options using their own switches which are included in
the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve
electronic connection between wheelchair controller and two or more power seating system motors, including
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
(CPT code E2311), expandable controller, including all related electronics and mounting hardware, upgrade
provided at initial issue (CPT code E2377) and harness for upgrade to expandable controller, including all
fasteners, connectors and mounting hardware, each (CPT code E2313), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received skilled care and improved, however your function had plateaued, and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care