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

We decided that the Plan does not have to pay forthe skilled nursing services provided from July 30, 2019 to August 6, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance. You also say that the provider rendered services that were medically necessary to the enrollee in good faith.The Plan denied your request. The Plan says there were a lack of medical records provided that are required to make a clinical determination of whether the services meet criteria for payment. 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 looked at the file and Medicare rules, andforMedicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 30, 2019 to August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveashower chair.You asked the Plan to pre-approvea shower chair. You say that you are weak and afraid of falling in the shower.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation provided on November 25, 2019.You asked the Plan to pay forthe periodic oral evaluation. You say that on the September 26, 2019 date of service no evaluation was done.The Plan denied your request. The Plan says this service exceeds the benefit allowance. The Plan also says this service is limited to one per every 12 months.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, you are limited to up to 1 oral exam(s) every 12 months. The record shows that you received an oral exam on September 26, 2019 and your oral exams benefit is now exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea removal of the torus mandibularis (D7473 x 2).You asked the Plan to pre-approvethe dental services. You say that you need these services in order to get dentures made. You also say that you have trouble eating.The Plan denied your request. The Plan says the removal of the torus mandibularis is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offersa 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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea removal of the torus mandibularis (D7473 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have been diagnosed with Charcot Marie Tooth disease, off the shelf inserts are no longer adequate because of your foot arches, and the custom inserts will help you to avoid stumbling and falling.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider. You asked the Plan to pre-approveout of network providers. You say that it is necessary for the enrollee to see the requested provider.The Plan denied your request. The Plan says it has a capitation arrangement with the contracted medical groups such that all medical services are the fiscal responsibility of the physicians of the group. They are also delegated to make the initial decisions as they have done here.  The Plan states the enrollee has seen two reconstructive surgeries through the Plan provider, which is rated as one of the top 100 hospitals in the United States.  The Plan states that while the requested provider is prestigious in a tertiary care center, it does not have a similar ranking. The Plan states the enrollee can be adequately treated in network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement of a spinal cord stimulator for the enrollee.You asked the Plan to pre-approvethe replacement. You say that this is medically necessary.The Plan denied your request. The Plan says the requirement for this request is that the existing device and/or battery is no longer underwarranty, and cannot be repaired.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the replacement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the current stimulator is not working.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 replacement have not been met.Therefore, we decided that the Plan does not have to pre-approvea replacement of a spinal cord stimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) for all 4 quadrants.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says periodontal scaling and rootplaning is not listed as a covered service.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, periodontal scaling and root planing is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that yourcondition needs daily wound care, antibiotics, and speech therapy.The Plan denied your request. The Plan says yourcurrent needs are being met in the current setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that you wereadmitted to the acute inpatient setting for the treatment of severe sepsis due to pneumonia with acute respiratory failure. Yourcomplex medical needs are being met in the current acute setting at this time. You donot 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 you requirethat 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 your diagnosis and condition.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you were out-of-town. You say that you were having increased heart palpitations and, on the recommendation of a friend, you went to see a doctor. You say that you did not know you should go to the ER or urgent care center.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 foran office visit provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient mental health care provided on September 6, 2019.You asked the Plan to waive the copayment foroutpatient mental health care. You say that you have never been charged in the past and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for outpatient mental health care. You have been asked to pay a $40 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 foroutpatient mental health care provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services (G0482) provided to the enrollee on July 15, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the medical records do not include definitive laboratory results for 15-21 drug classes to support the coding criteria for code G0482.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 G0482 is "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 find that CPT code G0482 is not supported in the medical record. Specifically, the records provided do not show that 15-21 drug classes were tested to support the billing of code G0482 on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services (G0482) provided to the enrollee on July 15, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe office visit provided on September 26, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you had your annual physical which should be free. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit medical records or a claim form showing the existing medical condition. Therefore, the plan hasnot shown that the copayment amount you are being asked to pay for the office visit is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment forthe office visit provided on September 26, 2019.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/orsend 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) provided on September 5, 2019.You asked the Plan to pay fora Tdap vaccine. You say that this was medically necessary.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine.Therefore, we decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) provided on September 5, 2019.Benefits for a Tdap vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission.You asked the Plan to pre-approvethe SNF admission. You say that you have been your wife's only caregiver for 8 years and have some medical issues of your own and can no longer handle this situation. It would be a danger for your wife to return home.The Plan denied yourrequest. The Plan says medical necessity cannot be established for SNF level of coverage.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 there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee 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-approveskilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (99232) provided on July 26, 2019.
You asked the Plan to pay for the outpatient visit. You say that modifier 24 indicates that this service should
not have been bundled. The Plan denied your request. The Plan says the office visit (99232), was bundled as
part of the global surgical fee because it was reported within 90 days of the major surgical procedure, 28810.
The Plan must follow Medicare rules. Medicare rules say that the global surgery package of procedure with a
global period of 90 days includes all additional medical or surgical services required of the surgeon during the
postoperative period of the surgery.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient visit have not been met. Specifically, the record indicates the office visit is part of
the post-operative services routinely performed by the surgeon. This service was rendered within the 90-day
global surgery period for 28810. Therefore, we decided that the Plan does not have to pay for an outpatient visit
(99232) provided on July 26, 2019.
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 enrollee needs supervision and safety cues. The Plan denied your request. The Plan says this is 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the submitted documentation, the enrollee has no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, the enrollee does not need skilled therapy on a daily basis. The enrollee 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
You asked the Plan to pre-approve the requested hospital bed. You say that you don't weight 300 pounds, but your dog and you together do. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. We looked at the file and Medicare rules. Based on the information provided, we decided that Medicare rules for coverage of the requested hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on September 5, 2019 by an out-of-network provider.
You asked the Plan to pay for specialist services. You say that you were unaware that provider was not in-network with your plan. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 specialist services provided on September 5, 2019 by an out-of-network provider.