Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 16, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there was no authorization for this service.
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 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 subsequent nursing facility care provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on April 19, 2021.
You asked the Plan to pay for the compression stockings. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. 

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial intraoral x-ray (D0220) and the additional intraoral x-ray (D0230) provided on April 5, 2021.
You asked the Plan to pay for the dental services. You say that you were instructed by the office staff that you would only have to pay $10 for a Covid-19 charge, and $20 for 1 x-ray that was not included. You also say that the rest of the charges should be covered. The Plan denied your request. The Plan says intraoral x-rays are not listed as covered services. The Plan also says that the bitewing x-rays and full mouth x-rays were paid.
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, intraoral x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial intraoral x-ray (D0220) and the additional intraoral x-ray (D0230) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the injection services provided on March 8, 2021.

You asked the Plan to waive the cost shares for the services provided. You say that it was just an injection, not an overnight stay. The Plan denied your request. The Plan says the cost share was applied per your plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

The file shows that you received a Triamcinolone injection. You have been asked to pay a 20% coinsurance for the drug. The service falls within the Medicare Part B prescription drugs benefit category.

The file shows that you received a lumbar epidural injection. This is considered an outpatient surgery service. You have been asked to pay $283.70 for the service. Because the amount is less than the $360 copay, you were charged the lesser amount. The service falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amounts 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 cost shares for the injection services provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the test to determine if prescription eye wear is needed (92015) provided December 16, 2020.
You asked the Plan to pay for the test to determine if prescription eye wear is needed. You say that this request should be considered medically necessary for your condition. The Plan denied your request. The Plan says this is not a covered benefit under Medicare, and you do not have supplemental insurance with the Plan that would cover a routine eye exam.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the test to determine if prescription eye wear is needed (92015) provided December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a prolonged hospital stay and an LTACH is more appropriate for the care the enrollee requires. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting. An LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured, and the appropriate level of care can be determined.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. Long-term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the medical management criteria and need for physician oversight. The Plan denied your request. The Plan says under Medicare, an IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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. Medical
conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 26, 2021.

You asked the Plan to pay for foot orthotics. You say that this was order and billed on different dates causing you to be responsible. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported because the enrollee has had progression while on previous immunotherapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requirements for coverage of Keytruda have not been met. Our physician reviewer found the records show that the enrollee has non-small cell lung cancer with progression on Imfinzi. Keytruda is not supported when there has been progression on a PD 1 inhibitor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 7, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that Cardiovascular Disease Screening must be billed with CPT codes 80061, 82465, 83718 or 84478. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment panel have not been met. Specifically, this claim has not been billed with the appropriate CPT codes for cardiovascular disease screening. Additionally, the documentation submitted does not include any clinical information to verify why this testing was ordered or how it would affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular gene testing provided on February 2, 2021.

You asked the Plan to pay for the testing services. You say that the test performed is valid with the procedure codes and diagnosis submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. In this case, there were insufficient medical records to show the results of the testing would be used in the management of a specific medical problem. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular gene testing provided on February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on February 11, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the services were previously approved and paid.
The Plan must follow Medicare rules. Medicare rules say that that claims or claim lines that have been determined to be exact duplicates of another claim are denied.
We looked at the file and the rules. We find that the additional billed CPT codes are not supported in the medical record. Specifically, the records do not indicate that additional x-rays were provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on February 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions are stable and they have no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the x-ray of the shoulder blade provided on March 22, 2021.
You asked the Plan to waive the copayment for the x-ray of the shoulder blade. You say that you do not feel you should be charged an additional copayment for a second x-ray. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 copayment for basic radiological services at a specialist's office. The Plan says you must pay a $25 copayment for the x-ray of the shoulder blade. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for the x-ray of the shoulder blade. You have already been asked to pay a $25 x-ray copayment on another claim, so an additional copayment does not apply to this claim. Therefore, we decided that the Plan has to waive the copayment for the x-ray of the shoulder blade provided on March 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve semi-electric hospital bed. You say that your current bed is not correct, and you want a new bed. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because your current hospital bed provided to you on November 7, 2019, is still within the 5-year reasonable useful lifetime and would need to be repaired rather than replaced.

The Plan must follow Medicare rules. Medicare rules say that replacement of equipment is not covered within the reasonable useful lifetime of the equipment. 

We looked at the file and Medicare rules. Your current hospital bed was provided to you on November 7, 2019. Therefore, this item is still within its reasonable useful lifetime and replacement is not covered at this time. Based on this information, we decided that Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that at home physical therapy is not helping you. The Plan denied your request. The Plan says you are medically stable and do not require intensive rehabilitation therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on March 8, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you do not understand why this service is not covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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, 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 comprehensive periodontal evaluation (D0180) provided on March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI provided on January 21, 2021.

You asked the Plan to pay for the MRI. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider you received these services from has opted out of the Medicare program.

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 MRI provided on January 21, 2021.