Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour blood glucose test strips.
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not the preferred product.
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 strips. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no justification for using this brand of test strips.
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 strips have not been met. Therefore, we decided that the Plan does not have
to pre-approve Contour blood glucose test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99213) provided on September 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 99213) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forinfection control supplies (S8301) provided on February 10, 2020.You asked the Plan to pay forthe infection control supplies. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code is not a valid code for Medicare purposes.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 code S8301 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S8301 has a status indicator of I. This means that CPT code S8301 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the infection control supplies have not been met.Therefore, we decided that the Plan does not have topay forinfection control supplies (S8301) provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care (99232) provided July 13, 2020.You asked the Plan to pay forthe subsequent hospital care. You say that records attached supporting that this procedure was performed by your provider. Claim denied as duplicate in error. Please review and reprocess claim for reimbursementThe Plan denied your request. The Plan says the claim was not billed with the appropriate modifier indicating that the denied service was unrelated and rendered during the post-operative period of a global procedure.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 billing of code 99232 was submitted inappropriately due to the bundled relationship of services within the specialty group. This service has already been paid to another physician. This code can only be billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care (99232) provided July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish, periodontal maintenance, and four gingival irrigations provided on September 22, 2020.You asked the Plan to pay forthe topical application of fluoride varnish, periodontal maintenance, and gingival irrigations. You say that you were told therewould be no cost to you for the service, and your insurance plan would cover it. You also say that you cannot afford this expense.The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify your benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride varnish, periodontal maintenance, and four gingival irrigations provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires supplemental oxygen, and has documented desaturation with activities that need to be monitored closely.The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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-approveacute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion.
You asked the Plan to pre-approve the lumbar fusion. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says the criteria for coverage have not been met because the notes do not show that the enrollee has stopped using nicotine products for a least 6 weeks.
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 lumbar fusion. Our reviewer says that lumbar fusion is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of smoking cessation. Smoking is a contraindication to fusion surgery. 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 lumbar fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an endosteal implant (D6010 x 3),
the semi-precision attachment abutment D6052 x 3), the overdenture (D5865), the connecting bar (D6055), the
initial 15 minutes of conscious sedation (D9239), and the additional 15 minutes of conscious sedation (D9243)
provided on July 7, 2020.
You asked the Plan to pay for the dental services. You say that you needed these services in order to get your
mouth ready for dentures. You say that you were diagnosed with squamous cell cancer. You say that you
needed these services so that you could go on with a normal life and be able to eat normally again. You also
say that when you contacted the plan, you were advised that the services should be covered by your major
medical and not dental. The Plan denied your request. The Plan says the services you received are dental in
nature. The Plan says that the dental services that you received are not covered.
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 an
endosteal implant (D6010 x 3), the semi-precision attachment abutment D6052 x 3), the overdenture (D5865),
the connecting bar (D6055), the initial 15 minutes of conscious sedation (D9239), and the additional 15
minutes of conscious sedation (D9243) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (00731) provided on August 3, 2020.
You asked the Plan to pay for anesthesia. You say that this service was correctly billed as an inpatient service. The Plan denied your request. The Plan says this service was billed as an outpatient service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. POS 21 indicates Inpatient Hospital, and POS 22 indicates On Campus-Outpatient Hospital. We find that the billing of this service is not supported in the medical record. Specifically, the record indicates that this service was rendered during an inpatient stay, but the claim was billed with POS 22 for outpatient services. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (00731) provided on August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 27, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you do not believe the copayment should apply in this situation. The Plan denied your request. The Plan says the copayment has applied correctly in this case.
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 $220 copayment for ambulance services. You have been asked to pay a $220 copayment for the ambulance services. The services provided fall 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 services provided on May 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 23, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were told that the hospital would absorb the costs since they were transporting you to another facility. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you have pain in your right shoulder and
cannot walk. You say that you live alone and are scared you will fall if you are sent home. The Plan denied
your request. The Plan says the guidelines for coverage of SNF care have 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 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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational
therapy in the SNF. By the dates in question, the enrollee was at a stand-by assist level with functional
mobility, including gait to 150 feet. The enrollee required varying assist with activities of daily living. 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 skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 14, 2020 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 medical services provided on September 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Partially Favorable

We decided that the plan has to waive the coinsurance for the radiation therapy. We decided that the Plan does
not have to waive the copayments for the lab services and CT scan.
You asked the Plan to waive the copayments for the lab services, radiation therapy, and imaging services. You
say that the copayments should be waived. The Plan says that the correct copayments have been applied.
We decided that the Plan has to waive the coinsurance for the radiation therapy. The record does not
show that radiation therapy services were performed on the date of service, therefore, this coinsurance was
applied incorrectly.
We also decided that the Plan does not have to waive the copayments for the lab services and CT scan.
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 lab services and a $195 copayment for advanced imaging services (including CT scans).
Therefore, we decided that the Plan does not have to waive the copayments for the lab services and CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on August 10, 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider billed codes 99203 (office visit) and 97035 (ultrasound therapy). These services are not covered when billed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided on August 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says this claim was no billed according to CMS
guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that in the case where the
beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene,
providers report the A0428 (BLS) HCPCS code.
We find that CPT code A0429 is not supported in the record. Specifically, this claim was not billed with the
appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance
services (A0429) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis provided on September 29, 2020.
You asked the Plan to pay more for the prophylaxis. You say that you are supposed to have 2 cleanings and an x-ray as needed for free. You say that you were left to pay $69, but it should be free regardless of who does it. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the allowed amount for a prophylaxis from an out-of-network provider. You are responsible for any remaining amount that exceeds the allowable charge from an out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the prophylaxis provided on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services (36415, 80053, 80162, & 80329)
provided April 4, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
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 36415, 80053, 80162, & 80329 are not supported in the medical record. Specifically,
the claim included an invalid revenue code. CPT code 80329 is marked with a status indicator of "I" and is not
valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the
outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for
outpatient hospital services (36415, 80053, 80162, & 80329) provided April 4, 2020.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 a LTACH. The 
enrollee still requires acute hospital level of care services and 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 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 LTACH services.