Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on October 13, 2020.

You asked the Plan to pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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 responsible for the 50% coinsurance plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on October 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says daily skilled services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this beneficiary 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-approve the SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic blood pressure monitor.

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the monitor is not covered by Medicare of the Plan.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an electronic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
received January 19, 2021.

You asked the Plan to pay for the limited oral evaluation - problem focused (D0140). You say that the
requested service was medically necessary. The Plan denied your request. The Plan says the requested service
is not covered under your supplemental benefit.

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. The Plan offers coverage for two periodic oral examinations per
calendar year and one comprehensive oral examination every three years. The Plan does not offer coverage for
problem focused examinations. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation - problem focused (D0140) received January 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from January 6, 2021, to January 7, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because the visit was necessary due to your medical condition. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided from January 6, 2021, to January 7, 2021.
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 the enrollee appears to be gradually stabilizing and improving but requires additional short-term acute care services for additional weaning and care which can be completed safely at the current facility until appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when treatment has been completed and the enrollee is appropriate for a lower level of 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. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.

You asked the Plan to pre-approve the mastectomy sleeve. You say that you need the requested item so that you can continue with physical therapy and keep the fluid down in your arm. You say that the therapy only helps relieve the swelling The Plan denied your request. The Plan says mastectomy sleeves are non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeves do not meet the definition of a prosthesis and are noncovered. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120),
prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided December 10, 2020,
by an OON provider.

You asked the Plan to pay for the dental exam, cleaning and bitewing x-rays. You say that you have been
seeing this dental provider for years and the services should be covered. The Plan denied your request. The
Plan says the services are not covered because the provider is OON.

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. The Plan covers the dental
exam, cleaning and bitewing x-rays when rendered by an in-network provider.

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the
Plan at the time of the service. 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. Based on this information, we decided
that the Plan's rules for coverage of the dental exam, cleaning and bitewing x-rays have not been met.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient
(D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided December
10, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that you were denied seeing the requested provider for pain management. The Plan denied your request. The Plan says in-network providers are available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 office visit with an out-of-network provider.
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 the enrollee was admitted with arm swelling form a nonocclusive thrombus and was anticoagulated. The enrollee recently developed bleeding and as ongoing transfusion requirements. The enrollee is not clinically stable. The enrollee continues to receive acute care services and have not been denied. The record does not indicate that the enrollee requires acute care services that they are not currently receiving that would be available at the LTACH facility. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time. 

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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography provided on November
18, 2020.

You asked the Plan to waive the copayment for the CT angiography. You say that the was the incorrect scan
and you should not be billed. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment after the deductible is met for each advanced imaging service (e.g., MRI, CT and PET scans,
nuclear medicine, and stress tests).

You have been asked to pay a $200 copayment for the CT angiography. The CT angiography falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the CT
angiography was performed. 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 CT angiography
provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 19, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair services coded 13121 provided on May 20, 2020.

You asked the Plan to pay for the repair services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. 

We find that CPT code 13121 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the repair services have not been met. Therefore, we decided that the Plan does not have to pay for the repair services coded 13121 provided on May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute rehabilitation services to be provided by an out of network provider.

You asked the Plan to pre-approve acute rehabilitation services with an out of network provider. You say that you want to stay at this facility. The Plan denied your request. The Plan says they will approve 7 more days acute rehabilitation at an in-network facility but not at the out of network facility.

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 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-approve acute rehabilitation services to be provided by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total left hip replacement for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the documentation did not show any discussion of a more conservative treatment, what has been done, and what the enrollee would not tolerate.

The Plan follows Medicare rules. Medicare rules say that a total hip arthroplasty can be covered if the LCD criteria are met. 

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 these services. Our reviewer says that a total left hip replacement is not medically reasonable and necessary for the enrollee. The enrollee was being treated for left hip pain; left-sided knee pain; left hip degenerative joint disease associated with hip hemiarthroplasty. She presented with worsening left knee pain with a history of previous left total knee arthroplasty and left hip hemiarthroplasty. Exam reveals she is wheelchair bound. The left knee has -5 degrees of extension, mild valgus and flexion beyond 60 degrees causes significant pain. There is good collateral ligament stability. There is fluid hip motion without pain. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Detailed documentation is not evident regarding any left hip deficits on exam. Furthermore, the results from the diagnostic injection provided on January 28, 2021 are not provided for review. Additionally, the x-rays, as noted on the January 15, 2021 exam, are not dated and show (relatively vague) degenerative joint disease of the acetabulum. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a total left hip replacement. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a total left hip replacement for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (HBO).

You asked the Plan to pre-approve the Hyperbaric Oxygen Therapy (HBO). You say that your provider asked for special oxygen treatments known as Hyperbaric Oxygen Therapy (HBO) because you have hearing loss. The Plan denied your request. The Plan says Hyperbaric Oxygen Therapy (HBO) for hearing loss is not listed as one of the indications for treatment with hyperbaric oxygen.

The Plan must follow Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy (HBO) will be limited to that which is administered in a chamber (including the one-man unit) and is limited to specific conditions.

We looked at the file and Medicare rules. The file shows that you are requesting coverage for Hyperbaric Oxygen Therapy (HBO) for hearing loss. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Specifically, Medicare does not cover HBO therapy for your medical condition. Therefore, we decided that the Plan does not have to pre-approve HBO therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on January 4, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that this copayment is too much, and you do not have much of an income. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $150 copayment for outpatient diagnostic tests/diagnostic radiological services. 

You have been asked to pay a $150 copayment for a CT scan. The correct copayment has been applied to the services provided. A CT scan falls within the outpatient diagnostic tests/diagnostic radiological 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 a CT scan provided by a participating provider on January 4, 2021.