Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 4 additional home health visits.
You asked the Plan to pre-approve the additional home health services. You say that you would like reconsideration because you are not at the same level as you were prior to entering the hospital. The Plan denied your request. The Plan says that you have met goals of care, and there is no plan of care reviewed by the doctor. The Plan also says that you have recovered your previous level of ability, and no further skilled needs are identified.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health services. Our reviewer says that the documentation in the case file supports that on April 19, 2021, the coverage criteria for four additional home health physical therapy visits were met for the enrollee in this case. Our physician reviewer found We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional home health services have been met. Therefore, we decided that the Plan has to pre-approve 4 additional home health visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Nutri-Pharmaceutical blend injections and electrical cell
stimulation (97032, 96372, 97150) provided May 26, 2020.
You asked the Plan to pay for the Nutri-Pharmaceutical blend injections and electrical cell stimulation. You say
that the treatment was medically necessary. The Plan denied your request. The Plan says this service is
considered experimental and is not covered.
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 the Nutri-Pharmaceutical blend injections and electrical cell stimulation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no professional society guidelines that support the use of the Sanexas machine along with (or without) subcutaneous vitamin injections. There is insufficient data in the medical literature to support the use of electrical nerve stimulation, vasopneumatic devices modality, and the injection of multivitamins for the treatment of the enrollee's conditions. 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 Nutri-Pharmaceutical blend injections and electrical cell stimulation have not been met. Therefore, we decided that the Plan does not have to pay for Nutri-Pharmaceutical blend injections and electrical cell stimulation (97032, 96372, 97150) provided May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of an inpatient admission provided on
October 13, 2020.
You asked the Plan to pay for continuation of an inpatient admission. You say that continued care was medically necessary. The Plan denied your request. The Plan says continued care can be provided at a lower level.
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 continuation of an inpatient admission provided on October 13, 2020. Our reviewer says that the continuation of an inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was a then, 62-year-old female who had a recent hospitalization for septic shock secondary to cecal perforation with pericecal/pelvic abscess status post laparotomy followed by abdominal washout and right colectomy with end ileostomy admitted on October 9, 2020 with hyponatremia, acidosis, and hypotension. Per the reviewed documentation, on October 13, 2020 the enrollee's high ostomy output was slowing down, vital signs were stable, electrolytes normal, the intravenous (IV) was discontinued, heart rate was 102, and afebrile. The attending notes stated the enrollee was stable for transfer back to facility, eating and taking medications by mouth. The review indicates that continuation of an inpatient stay for October 13, 2020 was not medically reasonable or necessary. The enrollee was stable and did not require any inpatient diagnostic studies or therapeutic interventions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of an inpatient admission provided from October 13, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for continuation of an inpatient admission provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) received February 23, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that cleanings billed under this procedure code have been covered in the past. The Plan denied your request. The Plan says the requested procedure is not covered under your 2021 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 periodontal maintenance procedure code is not listed on the benefit table in your 2021 EOC. Dental services not listed in this table are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) received February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (Current Procedural Terminology (CPT) code 87486, 87496, 87498, 87532, 87541,87581, 87631, 87640, 87798 and U0003) provided to the enrollee on December 28, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 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. Therefore, we decided that the Plan does not have to pay for the laboratory services (Current Procedural Terminology (CPT) code 87486, 87496, 87498, 87532, 87541,87581, 87631, 87640, 87798 and U0003) provided to the enrollee on December 28, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown (D2954) for tooth 28 and tooth 29.
You asked the Plan to pre-approve prefabricated post and core in addition to crown. You say that your dentist told you it is necessary to have this dental work completed right away to avoid further problems. The Plan denied your request. The Plan says this service was previously covered in 2017 and therefore the requested service is not yet eligible for coverage.
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 a prefabricated post and core in addition to crown once per tooth every 60 months. We looked at the file and Medicare rules. The Plan provided documentation showing that a prefabricated post and core in addition to crown for tooth 28 and tooth 29 was previously covered on May 20, 2017. Based on this information, we determined that the Plan's frequency limit has already been met at this time. Therefore, we
decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown (D2954) for tooth 28 and tooth 29.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy provided from August 26, 2020, to November 11, 2020.
You asked the Plan to waive the copayments for the physical therapy. You say that you do not believe you should have to pay for the services as the gyms were closed due to COVID-19. The Plan denied your request. The Plan says you were charged the copayments 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 $15 copayment for Outpatient Rehabilitation Services. You have been asked to pay a $15 copayment for each of the physical therapy treatments. The physical therapy falls within the Outpatient Rehabilitation 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 copayments for the physical therapy provided from August 26, 2020, to November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 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 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 lab work provided on December 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), and the gingival
irrigation - per quadrant (D4921) received December 28, 2021.
You asked the Plan to pay for the dental services. You say that the requested services should be covered by the
Plan. The Plan denied your request. The Plan says the requested services are excluded from coverage.
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 requested services are excluded from coverage under your Plan's
supplemental benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), and the gingival irrigation - per quadrant (D4921) received December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140), the immediate denture - mandibular (D5140), and the immediate denture - maxillary (D5130) received January 20, 2021 from the opt-out provider.
You asked the Plan to pay for the dental services. You say that you did not know that the provider needed to accept Medicare in order for the Plan to cover the services. The Plan denied your request. The Plan says this provider has opted out of Original Medicare.
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 has submitted evidence that this provider was opted out of
Original Medicare on this date of service. If you receive care from an opt-out provider then you must pay for the services yourself. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140), the immediate denture - mandibular (D5140), and the immediate denture - maxillary (D5130) received January 20, 2021 from the opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and electrical stimulation provided by a chiropractor on January 28, 2021.
You asked the Plan to pay for chiropractic services. You say that this visit has to take place before manual manipulation of the spine, and you believed this visit would be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan's when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit and electrical stimulation provided by a chiropractor on January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 30, 2021, through February 1, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was medically necessary. The Plan denied your request. The Plan says that based upon the available records, the care delivered is consistent with an observation stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on January 30, 2021 with weakness and a low hemoglobin. The enrollee has a known history of angioectasia. He was evaluated by Gastroenterology and transfused overnight with hemoglobin that was much improved and there were no ongoing signs or symptoms of active bleeding. The computerized tomography revealed a solitary 5mm focus of possible small bowel telangiectasias. Per the surgery consult, no intervention was needed unless acutely hemorrhaging. His condition stabilized and improved, and he was discharged February 1, 2021 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 30, 2021, through February 1, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 82955) provided March 5, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel. We looked at the file and Medicare rules. The panel was billed as unbundled codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 82955) provided March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is needed for monitoring rather than therapeutic reasons.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no reason given in the records why the enrollee is unable to use a glucometer. There is a requirement for three insulin shots per day. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. In addition, there is no documentation of an established
relationship between the enrollee and the ordering physician. Therefore, we decided that the Plan does not have
to pay for the laboratory services provided on November 13, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for tear of left Achilles tendon and
left peroneus brevis tendon, repaired surgically, and for lower extremity cellulitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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 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.