Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapy to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysical therapy. You say that you didn't feel safe having physical therapy in a small location where you cannot social distance.The Plan denied your request. The Plan says therapy is available at an in-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 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 physical therapy to be provided by an out of network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine home health nurse visits and 13 hours of home health aide services per week.
You asked the Plan to pre-approve home health services. You say that you need these services. The Plan denied your request. The Plan says these services are not medically necessary.
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 home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, or services in order to improve your condition or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not reveal new enteral feedings, need for IV antibiotics, a complex skin wound. You may contact your physician with medication or disease treatment questions. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve nine home health nurse visits and 13 hours of home health aide services per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on February 25, 2020.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 servicesat 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 nurse practitioner services provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services rendered on February 21, 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 88108 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 88108 and 88187. Code 88108 is a column II code with a modifier indicator of 1 when billed with column I code 88187. Code 88108 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the cytopathology services rendered on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on January 21, 2020 and February 20, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on January 21, 2020. The allowed amount is $100 and 20% of that is $25. You received a Medicare Part B drug on February 20, 2020. The allowed amount is $100 and 20% of that is $25. The total amount you owe is: $50. You have been asked to pay the total coinsurance amount of $50 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on January 21, 2020 and February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two pulp vitality tests (D0460 x2), extraction (D7140), oral hygiene instructions (D1330), and problem focused limited oral evaluation (D0140) provided on January 8, 2020 and February 3, 2020.You asked the Plan to pay forthe pulp vitality tests, extraction, oral hygiene instructions, and problem focused limited oral evaluation. You say that these services should be treated as a personal injury/accident claim.The Plan denied your request. The Plan says pulp vitality tests, extraction, and oral hygiene instructions are not covered benefits under the enrollee's dental plan. The Plan also says that problem focused limited oral evaluation exceeds the frequency limitation in the enrollee's benefit plan.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, pulp vitality tests, extraction, and oral hygiene instructions are not among those covered under this benefit. The contract clearly states that problem focused limited oral evaluation (D0140) is limited to one procedure per planyear. The record shows that you received a problem focused limited oral evaluation on February 3, 2020 and your problem focused limited oral evaluation has been exhausted.Therefore, we decided that the Plan does not have to pay forthe two pulp vitality tests (D0460 x2), extraction (D7140), oral hygiene instructions (D1330), and problem focused limited oral evaluation (D0140) provided on January 8, 2020 and February 3, 2020. Your complaint about the treating providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts and problem focused detailed and
extensive oral evaluation provided on March 12, 2020 by a general dentist.
You asked the Plan to pay for the diagnostic casts and problem focused detailed and extensive oral evaluation.
You say that you were told that you would be reimbursed for these services in the total amount. The Plan
denied your request. The Plan says diagnostic casts is not a covered benefit. The Plan also says that the
problem focused detailed and extensive oral evaluation is limited to being provided by an oral surgeon, and
was rendered by a general dentist.
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, diagnostic casts is not among those
covered under this benefit. The contract also clearly states that problem focused detailed and extensive oral
evaluations are a covered benefit when received by an oral surgeon. The record shows that you received a
problem focused detailed and extensive oral evaluation from a general dentist, hence, this service is not
covered. Therefore, we decided that the Plan does not have to pay for the diagnostic casts and problem focused
detailed and extensive oral evaluation provided on March 12, 2020 by a general dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced pneumatic compression device (PCD).
You asked the Plan to pre-approve the requested PCD. You say that the enrollee's lymphedema is not controlled with conservative therapy and failed to respond with the regular leg pump device. The Plan denied your request. The Plan says the enrollee's lymphedema is not extending onto the chest, trunk, or abdomen.
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications.
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 requested PCD. Our physician reviewer found that the enrollee was noted to have lymphedema due to vascular insufficiency. He tried a basic PCD, but it was discontinued as it caused trunk/chest/abdominal swelling and did not reduce swelling, exacerbated symptoms. The records do not show that the PCD is being requested to treat lymphedema extending onto the chest, trunk and/or abdomen. The physical exam findings indicate he has lower extremity only lymphedema. There are no objective measurements after a sufficient 4-week trial of a basic PCD, or objective reports, other than enrollee reports, of a use of a basic pump with a sufficient trial. Therefore, it is not clear that the lymphedema is unresponsive to all other clinical treatment over the course of a required four-week trial.
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 requested PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced pneumatic compression device (PCD).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse for resin-based composite - three surfaces, anterior (D2332) provided on November 27, 2019 by an out-of-network provider.
You asked the Plan to reimburse for the dental services. You say that you were told you had to pay 50% of the allowed amount and you thought your cost-share should have been $58.21. The Plan denied your request. The Plan says that you will be responsible for 50% of the allowed amount related to the out-of-network services.
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 does not say in clear and accurate terms how much you should expect to pay for out-of-network dental services. We looked at your contract with the Plan. The Plan must pay that additional charge. You say that you were told the Plan would pay 50% of the allowed amount. Your EOC states, "if you receive services from an out-of-network dentist, you will be responsible for 50% of the allowed amount." According to your EOC, 50% of the allowed amount would mean that you should only pay $58 and the plan should cover the rest. We did not see where the contract says enrollees must pay anything extra than the 50% of the allowed amount for out-of-network dental services. The Plan contract does not clearly say how much enrollees must pay for out-of-network dental services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to reimburse for resin-based composite - three surfaces, anterior (D2332) provided on November 27, 2019 by an out-of-network provider.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that without comprehensive, multidisciplinary approach, the enrollee is at high risk of recidivism.The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care 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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forrotary wing air transport (A0431) rotary wing air mileage (A0436) provided August 15, 2019.You asked the Plan to pay forthe air ambulance services. You say that you respectfully disagree with the determination and request the plan review the medical records and reprocess the claim for payment based on medical necessity of the services provided.The Plan denied your request. The Plan says this claim was billed incorrectly. The claim was not billed with a valid Typeof Bill.  A corrected claim must be resubmitted so that the claim can be reprocessed for payment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriateCPT code.We find that this claim was billed incorrectly. The claimwas not billed with a valid Type of Bill.  A corrected claim must be resubmitted so that the claim can be reprocessed for payment.Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forrotary wing air transport (A0431) rotary wing air mileage (A0436) provided August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Holter monitoring.
You asked the Plan to pre-approve the monitoring. You say that you want reconsideration for all of the other
denied codes. The Plan denied your request. The Plan says this is not medically needed at this time.
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 monitoring. Our reviewer says that
the requested monitoring is not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has increased coronary risk, but no documented cardiac symptoms in the medical
records, and no documented cardiac physical exam abnormalities. Therefore, the documentation does not
support the medical necessity for the testing in appeal. Screening stress testing even in high risk patients has
not been demonstrated to improve cardiac outcome.
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 monitoring have not been met. Therefore, we decided that the Plan does not
have to pre-approve Holter monitoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forportable oxygen equipment (E1390) provided March 12, 2020.You asked the Plan to pay forthe portable oxygen equipment. You say that the home oxygen equipment was medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.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 portable oxygen equipment. Our reviewer says that the oxygen equipment was not medically necessary. Our physician reviewer found the record shows an average oxygen saturation of 91%. Additionally, the oximetry report provided is dated January 24, 2008. No new oximetry data was provided. There is no clinical evidence provided to show the oxygen is medically necessary.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 portable oxygen equipment have not been met.Therefore, we decided that the Plan does not have to pay forportable oxygen equipment (E1390) provided March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physician's services. 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 physician's services provided on March 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need continued IV antibiotics and rehab
therapy. The Plan denied your request. The Plan says you are medically stable and have no complex wound
care needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that from a nursing perspective, you received IV and oral antibiotics. You had stable vital signs.
Regarding rehab services, you are at a standby assist to contact guard assist level with functional mobility. You
require varying assist with activities of daily living. Although there are identifiable skilled nursing and skilled
therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet
severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
February 4, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a wrist-hand orthosis (L3916) provided to the enrollee on February 4, 2020.