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 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services provided on September 30, 2020, by out-of-network providers.
You asked the Plan to pre-approve the medical services. You say that had you known you needed pre-approval you would have gotten it. The Plan denied your request. The Plan says the provider is not in-network and the services were not authorized to be rendered by an out-of-network provider.
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 pre-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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services provided on September 30, 2020, by out-of-network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), bone
replacement graft for ridge preservation (D7953) and extraction of erupted tooth (D7210) provided on February
13, 2020.
You asked the Plan to pay for the surgical placement of implant body, bone replacement graft for ridge
preservation, and extraction of erupted tooth. You say that these services were medically necessary. The Plan
denied your request. The Plan says these services are not covered by Medicare and you do not have a
supplemental benefit that covers dental services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant
body (D6010), bone replacement graft for ridge preservation (D7953) and extraction of erupted tooth (D7210)
provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 22, 2020.
You asked the Plan to pay for the medical services. You say that there is a business process by which VA Medical Centers are able to obtain Medicare-equivalent remittance advices for certain services. You feel that since this is not allowed for this service, the Plan should pay the claim. The Plan denied your request. The Plan says there is not sufficient information to support that this is a service that can be covered by a Medicare plan.
The Plan must follow Medicare rules. Medicare rules say that there are limited circumstances in which VA facilities may be paid for some Medicare-covered services. These claims must be processed by CMS directly. In this case, there is no documentation to support that payment can be made on this claim for services provided by a Federal facility. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the endodontic therapy (D3330), root amputation (D3450), and bone replacement graft (D4263) provided January 21, 2020, to February 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to reimburse you for the endodontic therapy, root amputation, and bone replacement graft. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this cost share processed correctly, and no reimbursement is due.
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. You have been asked to pay a total cost share of $1665.52 for the endodontic therapy. Of note, the Plan paid the 50% coinsurance ($319.48) of the allowed amount ($638.97); however, when services are obtained from an OON provider, the provider is allowed to bill the difference of the allowed amount and the amount they originally billed. Therefore, 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. Furthermore, although the Plan offers a dental benefit in excess of Medicare coverage, the root amputation and bone replacement graft are not covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the endodontic therapy (D3330), root amputation (D3450), and bone replacement graft (D4263) provided January 21, 2020, to February 11, 2020 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on June 5,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be
submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
practitioner services provided to the enrollee on June 5, 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 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 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 based on the medical records provided 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 require physical therapy and occupational therapy services but you do not require an
intensive inpatient rehabilitation therapy program. You will not be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to agitation and
resistance to participate due to fear of falling. Care at the skilled nursing facility level appears to be more
appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no need for physician supervision 3 times per week, or an intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that the enrollee was admitted to the acute hospital for surgical repair of an ankle fracture after a fall. She was discharged home then readmitted because of weakness and trouble ambulating. Her medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 23, 2020, through February 18, 2020, by an out-of-network provider.
You asked the Plan to pay for chiropractic services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the provider is not in-network and the services were not authorized to be rendered by an out-of-network provider.
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 chiropractic services provided from January 23, 2020, through February 18, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, heart, without contrast material, with
quantitative evaluation of coronary calcium (CPT Code 75571).
You asked the Plan to pre-approve the CT scan. You say that the member has just been recently determined to
have mild coronary artery and aortic calcified atherosclerotic disease. You state the member needs the imaging
test for their doctor to evaluate if additional treatment is needed. The Plan denied your request. The Plan says
this test is not medically needed to evaluate the amount of calcium in the heart vessels.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary. 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 CT scan. Our
physician reviewer found this is not a covered test under Medicare guidelines. Test has been denied, denial
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 the CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium
(CPT Code 75571).
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 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 you do not require services at the LTACH that are not available at the acute care
hospital where you are 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 you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON)
provider.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a
network provider.
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 pre-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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a CT scan to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on August 8, 2020.
You asked the Plan to pay for the emergency department visit and the electrocardiogram. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99285 and 93010 are not supported in the medical record. Specifically, these services were billed with an inappropriate primary, first-listed or principal code. The primary/first listed diagnosis code was T50.905A (adverse effect of unspecified drugs, medicaments and biological substances, initial encounter). Diagnosis code T50.905A is a secondary only diagnosis. A secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. Based on this information, we decided that Medicare rules for coverage of the emergency department visit and the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (PCD) rendered on August 4, 2020.
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 are not covered.
The Plan must follow Medicare rules. The rules say that claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) rendered on August 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional seven hours of home health aide services.
You asked the Plan to pre-approve additional home health aide services. 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 must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 additional home health aide services.
Our reviewer says that the documentation does not support that the requested services are medically reasonable
or necessary. Our physician reviewer found you have been receiving home health aide services. There is no
documentation that the unapproved seven hours of home health aide services are reasonable and necessary to
the treatment of your illness or injury by the skilled professional staff. You also receive four hours per day of
personal care services and have seven meals per week delivered. The requested additional home health aide
hours are 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 additional home health aide services have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional seven hours of home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you need dentures because you are unable to eat. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on January 17, 2018, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), platelet rich plasma, any site (0232T).
You asked the Plan to pre-approve the injection. You say that this has been recommended by various
physicians and specialists as your option. The Plan denied your request. The Plan says this service is listed as
experimental and investigation. There is limited long term medical studies to show it is safe and useful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve
injection(s), platelet rich plasma, any site (0232T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided March 23, 2020 to March 28, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were informed by the hospital that you should not have a copay. The Plan denied your request. The Plan says this claim processed and the correct copayment applied per the plan benefits.
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 $295 copayment per day, days 1-6 for Inpatient hospital care. You have been asked to pay $590 ($295 x 2 days) for 2 days of the inpatient stay. The inpatient stay falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided March 23, 2020 to March 28, 2020.