Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on July 2, 2021 and received physical and occupational therapy. You need varied assistance with sitting up, eating, and other activities of daily living. You have no skilled nursing or skilled therapy needs. You are at your functional baseline. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Onabotulinumtoxina injection.

You asked the Plan to pre-approve an Onabotulinumtoxina injection. You say that the services are necessar
y. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically reasonable and necessary when administered for specific circumstances. 

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 an Onabotulinumtoxina injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the record indicates that the enrollee has Raynaud's phenomenon with a non-healing wound of the left small finger. This is not one of the enumerated covered indication in the coverage criteria. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Onabotulinumtoxina injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Onabotulinumtoxina injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the form fitting conductive garment for delivery of TENS or NMES (E0731) provided February 17, 2021.
You asked the Plan to pay for the conductive garment. You say that documentation attached per request. Please process for payment. The Plan denied your request. The Plan says the records do not support the billed service. The provider is billing more than once for the same device/supplies.
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 E0731 is Form fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric). We find that CPT code E0731 is not supported in the medical record. Specifically, the delivery ticket indicated the item was shipped on November 23, 2020. However, the enrollee's claim history shows that the enrollee was also billed for the purchase and rental of the same Durable Medical Equipment (DME) supply from November 23, 2020 to February 17, 2021. The provider is billing more than once for the same device/supplies. Based on this information, we decided that Medicare rules for coverage of the conductive garment have not been met. Therefore, we decided that the Plan does not have to pay for the form fitting conductive garment for delivery of TENS or NMES (E0731) provided February 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health aide services.
You asked the Plan to pre-approve home health aide. You say that you cannot walk, and your hands are full of sores. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide. Our reviewer says that you do not meet the Medicare criteria for home health aide services. Our physician reviewer found there is no indication that you have a feeding tube, parenteral medications, or complex wound care issues. There is no indication that you have had any recent medication changes or hospitalizations. You have not had a recent decline in function and are medically stable.
You do not require skilled nursing services or skilled rehabilitation services to provide treatment that is medically necessary. The services you are requesting are custodial in nature and do not require a skilled professional to perform. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health aide services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 2, 2020.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that you cannot afford to pay for the core buildup. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 the core buildup, including any pins when required (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you are living at home and receiving home health skilled therapy. The physical therapy note on July 2, 2021 states that you need assistance to stand up and walk. You have no skilled nursing needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a transtelephonic pacemaker evaluation (93293) provided on
February 2, 2021, by an OON provider.

You asked the Plan to pay for a pacemaker evaluation. You say that the services were medically necessary. The
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services
rendered by an out-of-network provider.

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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a transtelephonic pacemaker evaluation (93293) provided on
February 2, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no red flags to mandate MRI without first attempting a 6-week trial of conservative therapy including physical therapy (PT). In particular, there is a normal neurological exam in the records and no history of trauma. Finally, a chiropractic referral is planned but no mention of PT. Medical necessity of MRI at this point without conservative management has not been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve total electric hospital bed. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered by
Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on February 24,
2021.

You asked the Plan to pay for the denture. You say that you were told these were pre-approved and would be
covered. You feel the dentures are necessary, but you would not have had them done if you knew they were not
covered, as you cannot afford this cost. The Plan denied your request. The Plan says these services are not
covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover
prosthodontic services.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial
upper denture (D5213) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 21, 2021.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that procedure code 99213 (office visit) was billed with POS code 60 for a mass immunization center setting. This POS code is not appropriate for the services at issue. 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 office visit rendered on January 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that the enrollee has several appointments to attend and needs transportation. The Plan denied your request. The Plan says this service is not covered under the member's benefit package.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The file shows that routine transportation is not a covered benefit under the enrollee's Plan. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on January 9, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this bill should be paid because you were incapacitated and couldn't get authorization. The Plan denied your request. The Plan says you were charged this copayment 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 $260 copayment per trip for ambulance services.
You have been asked to pay a $260 copayment per trip for the ambulance services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on January 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services and behavioral assessments provided on November 23, 2020, and January 25, 2021.

You asked the Plan to waive the copayments for specialist services and behavioral assessments. You say that the behavioral assessments had nothing to do with why you were at the appointment and you 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $25 copayment for outpatient diagnostic tests. 

You received specialist services on November 23, 2020. Therefore, you are responsible to pay the $45 copayment. You received a behavioral assessment on November 23, 2020. A behavioral assessment is considered an outpatient diagnostic test. Therefore, you are responsible to pay the allowed amount of $5.62, which is less than the $25 copayment. 

You received specialist services on January 25, 2021. Therefore, you are responsible to pay the $45 copayment. 

You received a behavioral assessment on January 25, 2021. A behavioral assessment is considered an outpatient diagnostic test. Therefore, you are responsible to pay the allowed amount of $5.38, which is less than the $25 copayment. 

The total amount you owe is: $101.

You have been asked to pay the total copayment amount of $101 for specialist services and behavioral assessments. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. Behavioral assessments fall within the outpatient diagnostic tests and therapeutic services and supplies 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 specialist services and behavioral assessments provided on November 23, 2020, and January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract removal provided on March 11, 2021.
You asked the Plan to waive the copayment for cataract removal. You say that you disagree with the charges because the surgery was not completed. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay the allowed amount of $303, which is less than the $395 copayment for cataract removal. Cataract removal falls within the outpatient surgery, including 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 does not have to waive the copayment for cataract removal provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 9, 2020.
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 37228 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 37228 is revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. We find that CPT code 37228 is not supported in the medical record. Specifically, there is no documentation of
an open or percutaneous endovascular revascularization of a unilateral tibial or peroneal artery. 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 surgical services rendered on March 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on September 29, 2020.

You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the eyeglasses (V2203, V2020, V2750, V2784) purchased on November 25, 2020.

You asked the Plan to pay the full amount for the eyeglasses. You say that you were told you would not be responsible for any additional charges for these glasses. The Plan denied your request. The Plan says there is a $200 maximum allowance for supplemental eyewear each year. The Plan has paid the full $200 allowance, but you are responsible for all charges over and above this amount.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 per year for supplemental eyewear. 

We looked at the file and the Plan's rules. The record shows that the full cost of the eyeglasses was $303. The Plan paid $200, and you are responsible for the remaining $103. This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay the full amount for the eyeglasses (V2203, V2020, V2750, V2784) purchased on November 25, 2020.