Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled nursing needs and you do not require daily skilled therapy at an inpatient level in a SNF. 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that LTACHs do not provide clinical advantage over a non-LTACH acute care hospitals.
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. 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 she 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the two breast ultrasounds you had on November 19, 2020.
You asked the Plan to reduce the copayment for the two breast ultrasounds. You say that you had this same test in 2019 and only had to pay $35.38. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amount for each ultrasound ($88.93) is less than your copayment obligation, you are responsible for the allowed amount for each service. The Plan also says that in 2019, ultrasounds were subject to 20% coinsurance, not a copayment, which is why the amount you were responsible for in 2019 was different. 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 $160 copayment for each Medicare-covered radiological diagnostic service, including ultrasounds. You have been asked to pay a $160 copayment for the two breast ultrasounds. 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 reduce the copayment for the two breast ultrasounds you had on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5964, L5845, L5828, L5856).
You asked the Plan to pre-approve the additional features. You say that this is medically necessary. The Plan denied your request. The Plan says a non-computerized prosthesis is available to meet the enrollee's needs.
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 additional features. Our reviewer says that the requested additional features are not considered medically reasonable and necessary in this case. Our physician reviewer found the protective outer surface covering system (L5964) is not medically necessary as the documentation does not reveal that this enrollee has special needs for protection against unusually harsh environmental situations. The L5845, L5828, L5856 requested items are not medically necessary, as these items exceed the enrollee's medical need. There is no evidence in the physician documentation that indicates that the enrollee would be unable to use a mechanical K3 leg rather than a microprocessor knee. 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 additional features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5964, L5845, L5828, L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation for a clinical trial to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the consultation. You say that you would like reconsideration because you were referred to this provider near your home for a clinical trial. The Plan denied your request. The Plan says you no longer qualify for a clinical trial so you can continue your care with your current oncologist.
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 provider at issue in this case is not a network provider with the Plan. 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 consultation. Our reviewer says that you are not eligible for a clinical trial. Our physician reviewer found your care may be rendered in-network. 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 consultation have not been met. 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 the consultation. Therefore, we decided that the Plan does not have to pre-approve a consultation for a clinical trial to be provided by an out-of-network (OON) provider.
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 criteria for admission 
to an acute inpatient rehabilitation setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 documentation does support a need for physical and/or occupational therapy, there is no documented 
need for an intensive, multi-disciplinary 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-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $325 copayment charged for ambulance transport provided to the enrollee on December 19, 2020.
You asked the Plan to waive this copayment. You say that this transport was Corona Virus related and should be no charge. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $325 copayment for ambulance transport. The enrollee has been asked to pay the correct amount based on the contract with the Plan. Medicare did not issue any waivers for ambulance cost share during the pandemic. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $325 copayment charged for ambulance transport provided to the enrollee on December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection procedure provided to the enrollee on June 26, 2020, at an ambulatory surgical center.
You asked the Plan to waive the copayment for the epidural injection procedure. You say that your husband did not get any relief from this procedure, so you don't think a copayment should apply. The Plan denied your request. The Plan says the enrollee was charged this copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for each procedure at an ambulatory surgical center. The enrollee has been asked to pay a $150 copayment for the epidural injection procedure. This copayment applies regardless of the outcome of the procedure. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the epidural injection procedure provided to the enrollee on June 26, 2020, at an ambulatory surgical center.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGen-Series and nutri-pharmaceutical specialized blend injections billed with CPT codes 97032, 97112 and 97016 and provided on December 14, 2020, through December 17, 2020.
You asked the Plan to pay for the Sanexas neoGen-Series and nutri-pharmaceutical specialized blend injections.. You say that you would like reconsideration because this machine is stand-alone therapy which has been cleared by the Food and Drug Association since 2004 for many indications. The Plan denied your request. The Plan says this service is experimental.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas neoGen-Series and nutri-pharmaceutical specialized blend injections. have not been met. Specifically, after review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Maine. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series and nutri-pharmaceutical specialized blend injections billed with CPT codes 97032, 97112 and 97016 and provided on December 14, 2020, through December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 10, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the enrollee on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2), and pontic (D6245) provided on March 17, 2021.
You asked the Plan to pay for the dental services. You say that you had carious lesion underneath your existing bridge. You say that the only way it could be treated was to remove the existing bridge. You also say that you now need a new bridge to be placed. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that retainer crowns are not listed as covered services. The Plan also says that pontic 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 Plans coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up, retainer crowns, and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2), and pontic (D6245) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for medical services provided at an out-of-network facility on March 17, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you were referred to this out-of-network 
facility because there were no plan providers who could offer the care needed. The Plan denied your request. 
The Plan says that this service is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The medical records and the letter from your primary care physician (PCP) clearly state that you were referred 
to this out-of-network facility by them.  Your PCP is a contract provider. There is no evidence that you were 
told prior to the services on March 17, 2021 that the medical services would not be covered. Furthermore, the 
Plan has provided no explanation as to why the 'facility ancillary' services provided on this date of service are 
non-covered.  There is no procedure code or specific non-coverage rule that the Plan has provided 
substantiating their denial.  The burden is on the Plan to show why their denial is appropriate.  We find that 
burden has not been met in this case. Under Medicare rules, this means the medical services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for medical services provided at an out-
of-network facility on March 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81206, 81210, 81272, 81292, 81295, 81298, 81301, 81317) provided October 27, 2020.
You asked the Plan to pay for the genetic testing. 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 to report a comprehensive genetic panel, service providers should use CPT code 81479. We looked at the file and Medicare rules. The genetic testing panel was billed using multiple unbundled CPT codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81206, 81210, 81272, 81292, 81295, 81298, 81301, 81317) provided October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, immunohistochemistry, and special stain
testing provided on December 8, 2020, billed with codes 88305, 88104, 88312, and 88361.
You asked the Plan to pay for the pathology testing. You say that this was medically necessary and should be
paid. The Plan denied your request. The Plan says these codes must be billed with modifier -26 as only the
professional component is payable.
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services is not
payable for services provided to a hospital outpatient.
In this case, the sample was taken from a hospital outpatient. The global fee for these codes was billed
(professional and technical) Payment cannot be made to an independent for the TC of these services. Therefore,
we decided that the Plan does not have to pay for the cytopathology, immunohistochemistry, and special stain
testing provided on December 8, 2020, billed with codes 88305, 88104, 88312, and 88361.
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 service is medically necessary. The
Plan denied your request. The Plan says the services 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 indicating medical necessity for the admission to
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital and does not require
services at the LTACH that are not available at the acute care hospital where currently receiving care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Specifically, medically necessary
services are being obtained at the enrollee's current level of care and does not need any additional services in a
LTACH. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided
that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.