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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee has not completed the full course of care in the hospital.
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 physician
reviewer found that the enrollee was admitted to the current acute care facility with cystitis and C-diff colitis
causing diarrhea. She was reported to have difficulty with oral intake. The enrollee appears to be more stable,
but requires only short-term acute care services which can be safely administered at the current facility. The
enrollee does not require services at the LTACH that are not already available at the current facility. Therefore,
this request for LTACH services will be considered not medically 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on September 8, 2020.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says providers should use CPT 81479 in this case.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 CPT code 81455  is "Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2,FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA,PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed."We find that CPT 81455 not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479.Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on September 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on
February 20, 2020.
You asked the Plan to pay for the services. You say that the treatment was rendered in good faith to the
enrollee. The Plan denied your request. The Plan says authorization for out-of-network services 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 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 outpatient mental health services provided to the
enrollee on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that the SNF is subpar care, and theenrollee needs more in-depth care.The Plandenied your request. The PlansaysMedicare criteria for coverage of the admission was not met.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 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 a humerus fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is a not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the abdomen
without contrast.
You asked the Plan to pre-approve CT scan. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because the preferred
modality for surveillance of the enrollee's condition is ultrasound.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 CT scan. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found CT of the
abdomen without contrast is not medically reasonable and necessary. Monitoring kidney stones for growth or
new stone formation can be safely accomplished with ultrasound.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Computed Tomography (CT) scan of the abdomen without contrast.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by provider on April 6, 2020.You asked the Plan to pay forthe ambulance services. You say that you did not request this service. The fire department was there for a broken water heater.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by provider on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe specialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe specialist services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are equally qualified in-network tertiary level specialists available to you that can provide the services you are requesting.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that the member's condition is getting worse and you wanted to find treatment that would stop progression and extend the life of the member. The Plan denied your request. The Plan says the services are not an emergency and the member's treatment can be safely rendered in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on September 4, 2020.You asked the Plan to pay forthese services. You say that the enrollee thought she would be reimbursed.The Plan denied your request. The Plan says the services were not purchased from the Plan provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Planpays for hearing aids only from a Plan provider.We looked at the file and the Plan's rules. The file shows that the enrollee did not purchase hearing aids from a Plan provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on September 4, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids providedon August 6, 2020.You asked the Plan to reimburse you for the hearing aids.The Plan denied your request. The Plan says hearing aids are not covered out-of-network.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAzacitidine for the enrollee.You asked the Plan to pre-approvethe requested drug. You say that this drug is medically necessary.The Plan denied your request. The Plan says the records show the enrollee is participating in a clinical trial. This request must be submitted to Original Medicare first.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. The rules say that services and drugs that are part of a clinical trial are covered by Original Medicare, not the Plan. The enrollee is participating in a clinical trial. Therefore, we decided that the Plan does not have to pre-approveAzacitidine for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skin surgery provided on June 16, 2020.You asked the Plan to waive the copayment forthe skin surgery. You say that you cannot afford this copayment. You say THE PLAN is not covering the hospital visit. The Plan denied your request. The Plan says youhave 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 $250 copayment for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $224.75 copayment, which is less than the standard copayment amount, for the skin surgery. The skin surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 doesnot have to waive the copayment forthe skin surgery provided on June 16, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on June 12, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says according to CMS Chapter 19 Section 100.5.1, all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under a certain revenue code on a certain type of bill code. The Plan is not allowed to explicitly state which codes to bill. The Plan has provided the CMS documentation which explains in detail how to bill for reimbursement. In this specific claim situation, the revenue code and type of bill code used are not correct. Because the claim was not billed in accordance with CMS guidelines, no payment was made. Therefore, THE PLAN is upholding its initial determination.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the type of bill code reported on the claim is not correct. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Adjacent tissue transfer or rearrangement services coded 14301, the immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction services coded 19340, the periprosthetic capsulectomy services coded 19371, and the mastopexy services coded 19316 provided on March 6, 2020.
You asked the Plan to pay for the Adjacent tissue transfer or rearrangement services, the immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction services, the periprosthetic capsulectomy services, and the mastopexy 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. We find that CPT codes 14301, 19340, 19371, and 19316 are not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of an adjacent tissue transfer or rearrangement, of any area, for defects 30.1 sq cm to 60.0 sq cm; therefore, code 14301 cannot be verified.
Procedure code 19340, an immediate insertion of a breast prosthesis following mastopexy, mastectomy or in reconstruction is documented in the operative note submitted for review; however, this procedure is considered inclusive to CPT code 19380, a revision of a reconstructed breast; therefore, the code cannot be verified.
Procedure code 19371-50-59, a periprosthetic capsulectomy, on the breast is documented in the operative note submitted for review; however, this procedure is considered inclusive to CPT code 19380-50-59, a revision of a reconstructed breast; therefore, the code cannot be verified. Procedure code 19316, a mastopexy is documented in the operative note submitted for review; however, this
procedure is considered inclusive to CPT code 19380-50-59, a revision of a reconstructed breast; therefore, the code cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the Adjacent tissue transfer or rearrangement services, the immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction services, the periprosthetic capsulectomy services, and the mastopexy services have not been met. Therefore, we decided that the Plan does not have to pay for the Adjacent tissue transfer or rearrangement services coded 14301, the immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction services coded 19340, the periprosthetic capsulectomy services coded 19371, and the mastopexy services coded 19316 provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 28, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that your provider should correct the code.The Plan denied your request. The Plan says the benefit for this service has been exhausted.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral evaluation when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The file indicates that you last received this service in January 2019 and therefore have exhausted this benefit until January 2022. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo unspecified restorative procedures (D2999) provided on December 30, 2019.You asked the Plan to pre-approvethe two restorative procedures. You say that you would like reconsideration because these services are covered and should be paid.The Plan denied your request. The Plan says this is not a Medicare or Plan 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-approvetwo unspecified restorative procedures (D2999) provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.
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 do not require the intensity of services provided at an IRF. Specifically, you are
not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician
evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF).