Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that 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 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 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-approveLTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on
January 20, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 $225
copayment per visit for outpatient surgery or procedure at an outpatient hospital.

Review of the file shows that you received outpatient hospital services on January 20, 2021. You have been
asked to pay a $225 copayment for these services. These services fall within the outpatient surgery or
procedure at an outpatient hospital 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 outpatient hospital services rendered on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continued inpatient care provided on November 16 to November 17, 2020.
You asked the Plan to pay for continued inpatient care. You say that the requested level of care was a medical necessity for the enrollee. The Plan denied your request. The Plan says continued inpatient care was not reasonable and necessary.
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 pay for continued inpatient care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that, on November 16 and November 17, 2020, the enrollee was hemodynamically stable and afebrile, no more procedures were planned, and lab values improving. The only main issue remaining for these last two days was poor oral intake which could be corrected with nasogastric tube feeds which were not contraindicated and could be administered via a lower level of care and not require close observation of glucose. Therefore, for these two remaining days, a lower level of care would have been more appropriate, according to the provided records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for continued inpatient care provided on November 16 to November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further for the routine eyewear services rendered on January 6,
2021.

You asked the Plan to pay further for these services. You say that you disagree with the charges. The Plan
denied your request. The Plan says the claim was processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $275 every year for routine eyewear.

We looked at the file and the Plan's rules. The file shows that you received routine eyewear services on January
6, 2021. You were not charged for the remake to bifocal lenses. The Plan applied the full $275 benefit for
routine eyewear. This did not cover the full cost of the services, so you have also been asked to pay a 20%
coinsurance for the remaining balance. Therefore, we decided that the Plan does not have to pay further for the
routine eyewear services rendered on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing coded 81455 provided on November 11, 2020.
You asked the Plan to pay for the genetic testing. 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 code 81455 is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX-Z code identifier should be entered adjacent to the code in the comment/narrative field. 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 the genetic testing coded 81455 provided on November 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31296 provided on November 9, 2020.
You asked the Plan to pay for the nasal/sinus endoscopy 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 31296 is nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium. We find that CPT code 31296 is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical nasal/sinus endoscopy, with dilation (balloon dilation) of the frontal sinus ostium; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the nasal/sinus endoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31296 provided on November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from December 7, 2020, to December 11, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 pay for the inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary in this case. Our physician reviewer found that the provided records show that there was no documentation that the enrollee was not stable for transfer on any of the dates of service. Based on the provided records, the enrollee appeared to be stable for transfer on December 7, 2020. He was hemodynamically stable and kidney function had stabilized. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from December 7, 2020, to December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 16, 2020.You asked the Plan to pay forthe 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 isrequired 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 forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing provided on April 30, 2020.
You asked the Plan to pay for lab test. You say that this testing should be covered based on the current federal guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee was enrolled in a hospice program for this date of service and therefore the Plan is not responsible for payment.
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 COVID-19 testing provided on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computerized tomography (CT) capture and
interpretation with limited field of view - less than one whole jaw (D0364) provided October 23, 2020.
You asked the Plan to pay for the cone beam CT scan. You say that you were told the services would be
covered. The Plan denied your request. The Plan says an exception has been made to cover the services from
this provider as in-network. However, the cone beam CT scan is not a covered service under your dental
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 for the cone
beam computerized tomography (CT) capture and interpretation with limited field of view - less than one
whole jaw (D0364) provided October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit or pay for the dental services provided from October 1, 2020, to December 11, 2020.

You asked the Plan to waive the copayment for the office visit and pay for the dental services. You say that you were advised that there would be no copayment for any of the appointments that you had. You say that the costs are unreasonable. You say that you should have been made aware of these costs at the time you received the services. You also say that you cannot afford to pay these bills. The Plan denied your request. The Plan says there is a $35 copayment for physician services that you receive in network. The Plan says that there is a $700 allowance each year for non-Medicare covered dental services. The Plan also says that the $700 allowance has been exceeded.

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 $35 copayment for Physician 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.

You have been asked to pay $35 copayment for the physician service. the physician service falls within the Physician 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. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the $700 allowance has been exceeded.

The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit or pay for the dental services provided from October 1, 2020, to December 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that you feel that the plan should cover for the SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on October 15, 2020.

You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered for the indications established in the applicable LCD. 

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 pay for the drug testing. Our reviewer says that the requested drug testing was not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 70-year-old female who underwent drug testing (definitive) on October 15, 2020. No opioid use or other drug use was reported to justify this testing. There were no physical findings suggestive of possible drug abuse. Also, definitive testing is meant to follow-up on confusing drug screening tests, and there were no provided screening tests with confusing results to justify definitive testing for this enrollee. Therefore, this request for the definitive drug testing is considered not medically reasonable and necessary based on the provided documentation. 

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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup procedures (D2950), a porcelain pontic (D6240) and retainer crowns (D6740) provided on January 21, 2021.
You asked the Plan to pay for the dental services. You say that you have a $1,000 dental allowance and feel it should cover these services. You feel you have been given misleading or inaccurate information. The Plan denied your request. The Plan says these services are not covered under your supplemental dental 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. Therefore, we decided that the Plan does not have to pay for core buildup procedures (D2950), a porcelain pontic (D6240) and retainer crowns (D6740) provided on January 21, 2021.
Your complaint about a potential miscommunication or misinformation from the Plan or the dental provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the rotating swivel car seat purchased on December 14, 2020.

You asked the Plan to reimburse you for the rotating swivel car seat. You say that because of your medical condition you need this seat. The Plan denied your request. The Plan says this seat is not covered by Medicare or the Plan and you have a Transportation benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to reimburse you for the rotating swivel car seat purchased on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe infusion supplies (A4221 and A4222) provided on October 27, 2020, through November 2, 2020.You asked the Plan to pay forthe infusion supplies. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation submitted does not include an itemized billing or shipping invoice to verify the billed supplies.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record contains a valid proof of delivery for the supplies provided in this case. Based on this information we have decided that Medicare coverage criteria for the infusion supplies have been met.Therefore, we decided that the Plan has to pay forthe infusion supplies (A4221 and A4222) provided on October 27, 2020, through November 2, 2020