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 enrollee can't return home.The Plan denied your request. The Plan says the services are 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 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 requestto pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a left femur fracture and underwent surgical repair on January 31, 2020. As of February 19, 2020 she is walking 40 feetwith a rolling walker and assistance. She has no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 1, 2019.

You asked the Plan to pay for the physician services. You say that the services provided were not related to hospice care. The Plan denied your request. The Plan says during the hospice election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 the office visit provided on October 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cystoscopy provided on March 26, 2019.You asked the Plan to waive the copayment forthe cystoscopy. You say that you had an ultrasound and the provided has billed you incorrectly. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $350 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.You have been asked to pay a$350 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows you had a cystoscopy procedure on March 26, 2019.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 forthe cystoscopy provided on March 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 12, 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 fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix.You asked the Plan to pre-approve these services. You say that the enrollee has a low white blood cell count.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that Granix is covered when specific 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 the services are not medically necessary. Our physician reviewer found the enrollee has neutropenia related to medications he takes due to kidney transplant. The records do not support that he has a diagnosis for which Granix is covered by Medicare. The medication is not reasonable ormedically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 1, 2019.You asked the Plan to pay for the physician services. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.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 the hospital outpatient clinic visit provided on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the out-of-network coinsurance for radiation therapy.
You asked the Plan to waive the out-of-network coinsurance for radiation therapy. You say that the enrollee requires specialized treatment only available with this provider. The Plan denied your request. The Plan says these services have been approved through the point-of-service benefit and the enrollee will be liable for the out-of-network coinsurance.
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 20% coinsurance for services under the POS benefit with a provider that accepts Medicare assignment. You have been asked to pay a 20% coinsurance for radiation therapy from an out-of-network provider. The Plan has approved these services under the POS benefit and has network providers available who can provide the services at issue in this appeal. 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 out-of-network coinsurance for radiation therapy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forcataract surgery provided on August 27, 2019.You asked the Plan to pay forcataract surgery. You say that the procedure is not related to hospice. You say that the claim should be reprocessed.The Plan denied your request. The Plan says Original Medicare is 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 forcataract surgery provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered to the enrollee on September 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 44238 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 44238 is unlisted laparoscopy procedure, intestine (except rectum).We find that CPT code 44238 is not supported in the medical record. Specifically,the records do not contain documentation of an unlisted laparoscopy procedure of the intenstine. 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 forthe surgical services rendered to the enrollee on September 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (code D2950).
You asked the Plan to pre-approve core buildup. You say that the enrollee is in severe pain. The Plan denied your request. The Plan says this service is not listed as a covered 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 pre-approve a core buildup, including any pins when required (code D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 5, 2019 to May 1, 2019.You asked the Plan to pay for the skilled nursing services. You say that the responses have varied and currently state that the provider is out-of-network. You also say that this is inaccurate because previous services you have received by this provider were covered.The Plan denied your request. The Plan says the skilled nursing stay was no longer medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from April 5, 2019 to May 1, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Dual-energy X-ray absorptiometry (DXA) bone density study(77080) provided on August 16, 2019.You asked the Plan to pay for the DXA Bone Scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were non-emergent and were not preauthorized. The enrollee has no out-of-network benefits.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 forthe Dual-energy X-ray absorptiometry (DXA) bone density study (77080) provided on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on September 25, 2019.
You asked the Plan to pay for the resin-based composites. You say that since you had not claimed any payment for dental services in quarters 1 or 2 of 2019, there should have been a total of $1,350 available for payment of this claim. The Plan denied your request. The Plan says you received dental services on August 15, 2019, August 19, 2019, and August 28, 2019 in which your comprehensive dental service applied towards your rolled over allowance for the third quarter, exhausting your 1st, 2nd, and 3rd quarter benefit allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $450.00 allowance for comprehensive dental services every quarter. The record shows that you met the quarterly allowance on August 28, 2019 and your quarterly allowance was then exhausted. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for28 electrodes (A4556) provided on March 6, 2019 through September 14, 2019.You asked the Plan to pay for the electrodes. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per Medicare guidelines, the HCPCS billed is not valid for claim submission.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 A4556 is not supported in the record. Specifically, per Medicare, A4556 is not valid for claim submission. Based on this information, we decided that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for 28 electrodes (A4556) provided on March 6, 2019 through September 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. The Plan denied your request. The Plan says SNF admission 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 above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the records do not support that the enrollee in this case needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. The Plan denied your request. The Plan says that this is not medically necessary.
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 pre-approve proton beam therapy. Our reviewer says that the requested proton beam therapy is considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has locally advanced squamous cell carcinoma or the sinus. Per NCCN radiation compendia for resected squamous cell carcinoma of the sinus, proton beam radiation is an accepted modality. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit on March 2, 2019.You asked the Plan to waive the copayment fora specialist office visit. You say that this should be considered post-op appointment.The Plan denied your request. The Plan says post-op apportionment are still subject to a copayment; therefore, 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 $45 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $45 copayment for a specialist office visit. a specialist office visit falls within thephysician/practitioner services/specialist visit 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist office visit on March 2, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 1, 2018 to December 31, 2018.You asked the Plan to pay for the skilled nursing services. You say that these services were medical because of the enrollee's diagnoses.The Plan denied your request. The Plan says this provider is not certified with Medicare and therefore, the services are not covered by the Plan.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 1, 2018 to December 31, 2018.