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

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from, May 13, 2021.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient mental health care. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan, however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 13, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from, May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set and infection control supplies rendered on October 10, 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 codes S1015 and S8301 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set and infection control supplies rendered on October 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 28, 2020.
You asked the Plan to pay for the drug testing. 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 payable.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from February 5, 2020, to December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not eligible to enroll in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received from February 5, 2020, to December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia. Our reviewer says that based on the records provided, the member has not tried an failed the Plan's required drug, zoledronic acid. Our physician reviewer found there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the member.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 10, 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 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive. We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not show a surgical shoulder arthroscopy with extensive debridement, including three or more discrete structures, was performed. 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 December 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you no longer require skilled services and the continuation of SNF 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF services.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 6, 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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on September 16, 2020.

You asked the Plan to waive the copayment for arthrocentesis. You say that you were not charged in the past for the same procedure and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

The record shows that you received arthrocentesis on September 16, 2020, at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. 

You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis 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 does not have to waive the copayment for arthrocentesis provided on September 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs appear to be custodial in nature.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the partial upper denture. We decided that the Plan does not have to pre-approve the core build up.
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says 1 upper denture is covered every 5 calendar years. The Plan says that the frequency limit for this service has been reached. The Plan also says that core build up is not listed as a covered service.
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.
We decided that the Plan has to pre-approve a partial upper denture.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. The record shows that the provider's office confirmed that the claim for the previous partial upper denture had been voided. The provider's office also confirmed that no partial upper denture had been provided to the enrollee. Therefore, we decided that the Plan has to pre-approve a partial upper denture.
We also decided that the Plan does not have to pre-approve the core build up.
Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core build up.
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 shoulder elbow wrist hand orthosis (L3960) provided August 21, 2020.

You asked the Plan to pay for the orthosis. You say that please find the attached documents and reprocess the claim towards payment.The Plan denied your request. The Plan says the documentation does not sufficiently document the enrollee's medical condition to support medical necessity and there is no evidence of an established relationship between the enrollee and the ordering physician.

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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder.

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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 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 for the services provided by an out-of-network provider on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for incisional biopsy of oral tissue, soft, (D7286) provided on November 2, 2020.

You asked the Plan to pay for the dental service. You say that the pathologist service was covered. You say that you thought this would be covered too. You also say that at least part of this claim should be paid. The Plan denied your request. The Plan says incisional biopsy of oral tissue, soft, is not listed as a covered service.

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 pay for incisional biopsy of oral tissue, soft, (D7286) provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 for the services provided by an out-of-network provider on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) provided November 20, 2020.

You asked the Plan to pay for the knee orthosis. You say that this request was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include proof of delivery or delivery ticket to indicate the specific supplies.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery. The documentation submitted does not include a proof of delivery to indicate the enrollees received the durable medical equipment. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) provided November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S0119) provided on July 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a payable service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S0119 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S0119) provided on July 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 31, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's conditions. In general, screening tests are permitted in limited circumstances and must be accompanied by proper documentation and coding, while diagnostic tests must be related to a specific sign or symptom. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 31, 2020.