Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on October 3, 2019 by an out of network (OON) provider. You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on October 3, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DARZALEX Faspro for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says use of this drug requires no experiencing of disease progression.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the notes appear to state the plan is with three separate drugs. The hand-written note states that enrollee has progressed on DARZALEX and that is a reason for it to not be approved. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve DARZALEX Faspro for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for respiratory virus detection testing provided on March 4, 2020.
You asked the Plan to pay for lab test. You say that you only perform this testing in your hospital laboratory, so it should be covered. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for lab test. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in the current coronavirus disease 2019 (COVID-19) climate, the diagnosis of respiratory syncytial virus (RSV) would further confidence that the enrollee is not a false negative COVID-19 patient or not a COVID-19 patient pending test results. Important information regarding isolation and prognosis can be gained. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lab test have been met. Therefore, we decided that the Plan has to pay for respiratory virus detection testing provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on December 30, 2019.
You asked the Plan to pay for the compression stockings. You say that you require the stockings to treat lymphedema. The Plan denied your request. The Plan says the compression stockings are noncovered because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteogenesis stimulator (E0747).
You asked the Plan to pre-approve Osteogenesis stimulator. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says the criteria has not been met as
there are no post-operative x-rays showing failed fusion after nine months have elapsed since the last surgery as
last surgery occurred 2 months ago on 04/17/20.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had
ceased. Therefore, we decided that the Plan does not have to pre-approve Osteogenesis stimulator (E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture teeth 1 and 16 (D5110) immediate lower denture teeth 17 and 32 (D5140) alveoloplasty in conjucture with extractions teeth 1, 8, 9 and 16 (D7310) and removal of torus mandibularis teeth 17, 24, 25, and 32 (D7473) provided January 14, 2020 to February 19, 2020.You asked the Plan to pay for the dental services. You say that in the benefits highlights booklet, dental coverage is $1000. no exceptions. This work was part of a complete dental procedure you had done on your teeth.The Plan denied your request. The Plan says these services are not covered under the plan benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit thatexceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed under the list of covered dental procedures are not covered by the plan.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 forcomplete upper denture teeth 1 and 16 (D5110) immediate lower denture teeth 17 and 32 (D5140) alveoloplasty inconjucture with extractions teeth 1, 8, 9 and 16 (D7310) and removal of torus mandibularis teeth 17, 24, 25, and 32 (D7473) provided January 14, 2020 to February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home day life activity services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these services would be considered a custodial/homemaker service.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no medical records have been submitted for review. Therefore, there is no evidence that the enrollee requires, or is receiving, skilled nursing services or skilled therapy services. In the absence of skilled needs, HHA services are not covered. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home day life activity services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 20, 2019. 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 procedure code G0481 is not supported. 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 G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. 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 pay for the drug testing rendered on August 20, 2019.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an observation stay provided from February 26, 2020 to February 28, 2020.You asked the Plan to waive the deductible and copayment foran observation stay. You say that you were admitted to the hospital and disagree with the charges.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. Your contract with the Plan says that there is a $750 deductible. Your contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $125 copayment for outpatient hospital observation. The medical records show that you had an observation stay from February 26, 2020 to February 28, 2020. The record shows that you had only paid $154.60 toward the $750 deductible. Therefore, you are responsible to pay the remaining deductible balance of $595.40. Now that the $750 deductible has been met, you are also responsible to pay the $125 copayment. The total amount you owe is $720.40.The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient hospital observation. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. The Plan has also followed Medicare rules by clearly disclosing in the contract that after the $750 deductible has been met, enrollee's must pay a $125 copayment for outpatient hospital observation. This cost sharing is a contractual obligation that had not been met at the time an observation stay was received on February 26, 2020 to February 28, 2020.Therefore, we decided that the Plan does not have to waive the deductible and copayment for an observation stay provided from February 26, 2020 to February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical exam and evaluation (92002) and fundus
photography (92250) spherocylinder, single vision lens (V2103) and polycarbonate lens (V2784).
You asked the Plan to pay for the vision services. You say that you have provided the vision care benefit
summary and a printout from the provider with an authorization ID number. You are confused why the
provider received authorization. The Plan denied your request. The Plan says enrollee's must receive their
vision services from an in-network provider.
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 these services when rendered by an in-network participating vendor.
We looked at the file and the Plan's rules. Services rendered by an out of network provider are not covered by
the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not
been met. Therefore, we decided that the Plan does not have to pay for the medical exam and evaluation
(92002) and fundus photography (92250) spherocylinder, single vision lens (V2103) and polycarbonate lens
(V2784).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Comprehensive Cardiomyopathy NGS Panel.
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says the test request was received, but no narrative description was provided to identify the genetic testing performed.
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 panel. Our reviewer says that the requested panel is not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the requested testing is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the Comprehensive Cardiomyopathy NGS Panel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 9, 2019. 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 procedure code G0482 is not supported. 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 G0482 is definitive drug testing, 15-21 drug classes. We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation of testing of 15-21 drug classes. 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 pay for the drug testing rendered on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 18, 2019.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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 you require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided the complexity of your nursing, medical and rehabilitation needs you do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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.