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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy.

You asked the Plan to pre-approve colonoscopy. You say that you had a colonoscopy 5 years ago which found polyps and are at high risk. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not meet the criteria for a 5-year interval colonoscopy.

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 colonoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found available records support that the enrollee's next medically appropriate colonoscopy reverts to an every 10-year study interval. The enrollee has no history of adenomas and her one first-degree relative was diagnosed at over age 60. This time frame corresponds to the guidelines. The enrollee does not meet criteria for a 5-year interval colonoscopy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an intraoral complete series of radiographic images (D0210), and topical application of fluoride (D1206) provided on March 29, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, a teeth cleaning, an intraoral complete series of radiographic images, and topical application of fluoride. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, an intraoral complete series of radiographic images, and topical application of fluoride have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 

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 a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an intraoral complete series of radiographic images (D0210), and topical application of fluoride (D1206) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Freestyle kit provided on April 5, 2021.

You asked the Plan to waive the coinsurance for the Freestyle kit. You say that you saw the kit on tv and that it is free with Medicare. You say that you want it to be completely covered. 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 20% coinsurance for Medicare-covered durable medical equipment.

You have been asked to pay $64.35, which is 20% of the allowed amount for the Freestyle kit. The Freestyle kit falls within the "Durable medical equipment (DME) and related 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 coinsurance for the Freestyle kit provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479, 81226, 81227, 81291, 81355, 81401) provided December 9, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that if there is no CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted CPT code 81479 with a single unit of service. We looked at the file and Medicare rules. The testing performed was billed using unbundled codes instead of a single unit of CPT code 81479. 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 lab services (81479, 81226, 81227, 81291, 81355, 81401) provided December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical needs require acute rehab. The
Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan
says that the enrollee could receive the care needed in another setting.
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 and back pain and had L4-L5 decompression. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion tomographic imaging (78452) provided on July 20, 2020, by an out of network provider.
You asked the Plan to pay for myocardial perfusion tomographic imaging. You say that the requested services were a medical necessity for the enrollee. 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 myocardial perfusion tomographic imaging (78452) provided on July 20, 2020, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).

You asked the Plan to pre-approve SI RFA. You say that your pain is constant. The Plan denied your request.
The Plan says the denial of authorization for this service is correct, because SI RFA is
experimental/investigational.

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 SI RFA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found at this time; the requested procedure has a lack of standardized technique which prevents
definite conclusions on the efficacy of this procedure. A review of the literature shows that additional highquality,
large randomized controlled trial research is needed to determine the long-term outcomes and best
candidates and treatment parameters for this procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to
pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 84481, 84681, 84144, 83525, 82670, 83001, 83002, 82533, 84403, 83970, 82610) provided to the enrollee on December 15, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because screening testing is not a Medicare benefit when done without documentation of medical indication from the treating provider.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, the laboratory services, 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 for the laboratory services (CPT code(s): 84481, 84681, 84144, 83525, 82670, 83001, 83002, 82533, 84403, 83970, 82610) provided to the enrollee on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the battery charger (E2366) purchased February 15, 2021, from a provider not certified with Medicare.

You asked the Plan to pay for the battery charger. You say that you would like to be reimbursed as this was an emergency. The Plan denied your request. The Plan says the provider is not certified with Medicare and not eligible for payment.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the battery charger (E2366) purchased February 15, 2021, from a provider not certified with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (G0463, 99203) provided on February 23, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-approved. There were network 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 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 services at issue in this appeal. The Plan did not pre-approve the service 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 services (G0463, 99203) provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital observation services provided on July 23, 2020, by an out of network provider.

You asked the Plan to pay for outpatient hospital observation services. You say that the services at issue were a medical necessity for the enrollee. 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 outpatient hospital observation services provided on July 23, 2020, by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404) provided February 12, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. 

We looked at the file and Medicare rules. The test at issue is non-covered. 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 lab services (81404) provided February 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance transportation (A0427, A0425) provided on January 22, 2021.

You asked the Plan to pay for emergency ambulance transportation. You say that the service was medically necessary, and you want the Plan to pay. The Plan denied your request. The Plan says the services at issue were not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 emergency ambulance transportation. Our reviewer says that the provided documentation does not support that the ambulance transport was medically necessary for the enrollee. Other means of transportation were not contraindicated and would have been more appropriate as the enrollee did not require special equipment or experts during the transport, based on the provided documentation. Our physician reviewer found the enrollee had nausea and weakness for 3 days. Vitals were stable on Emergency Medical Services arrival.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of emergency ambulance transportation have not been met. Specifically, criteria for medical necessity of an emergency ambulance transportation were not met. Therefore, we decided that the Plan does not have to pay for emergency ambulance transportation (A0427, A0425) provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor provided March 23, 2021.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the documentation submitted is missing information required for payment.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor provided March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.

You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says continued SNF services are not medically necessary.

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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You were treated for pain. You had uncomplicated wound care to your right lower extremity. You were to complete a course of daily intravenous antibiotics until August 7, 2021. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, you were at a standby assist level with functional mobility including gait to 120 feet with a rolling walker. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax for the durable medical equipment purchased June 3, 2020.

You asked the Plan to pay for the sales tax for the durable medical equipment. You say that you would like this claim reimbursed. The Plan denied your request. The Plan says sales tax is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sales tax for the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the sales tax for the durable medical equipment purchased June 3, 2020.