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

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of inpatient skilled nursing facility care.

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 care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee had a fall with a left femur fracture and right total knee replacement. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She was treated for post-operative anemia and pain. The enrollee received physical and occupational therapy in an acute hospital. The enrollee was at a supervision to contact guard assist level with functional mobility including gait to 100 feet with a rolling walker. She required varying assist with activities of daily living. The enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine rendered on August 13, 2020 to August 17, 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 services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on August 13, 2020 to August 17, 2020.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ambulance trip provided on June 3, 2020.

You asked the Plan to waive the deductible for an ambulance trip. You say that you thought your copayment would be $270. The Plan denied your request. The Plan says the correct deductible has been applied.

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 there is a $1,000 deductible for ambulance services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the time an ambulance trip was received on June 3, 2020. The total amount you are being asked to pay is $505.25. Therefore, we decided that the Plan does not have to waive the deductible for an ambulance trip provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits (99212).

You asked the Plan to pay for the office visit. You say that before you began chiropractic treatment you called the Plan to see if he was a network provider. You started treatment and every claim submitted by the doctor's office is denied. The Plan denied your request. The Plan says this service is not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visits (99212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (93010, 99285).

You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with a correct primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug.

We looked at the file and Medicare rules. The billed primary diagnosis on this claim is T38.0X5A , adverse effect of glucocorticoids and synthetic analogues, initial encounter. The nature of the adverse effect should be coded first instead. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (93010, 99285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367).

You asked the Plan to pre-approve cone beam CT capture and interpretation. You say that the enrollee needs a CT scan before a pre-authorization for implants can be sent. The Plan denied your request. The Plan says this service is not covered under 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, 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 a cone beam CT capture and interpretation (D0367).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density test provided on July 23, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says they are unable to determine whether the services were medically necessary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the services at issue are not supported. The file shows that the Plan made several attempts to obtain the necessary documentation without success. 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 bone density test provided on July 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on August 29, 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 not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be reported under revenue code 0510 and TOB 13x. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required revenue code and TOB. 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 emergency room (ER) services rendered on August 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) services coded 78815 provided on September 28, 2020.

You asked the Plan to pay for the PET with CT scan services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 78815 is positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. 

We find that CPT code 78815 is not supported in the medical record. Specifically, this service was reported with diagnosis code C50.912 (Malignant neoplasm of unspecified site of left female breast). This is not an appropriate diagnosis code for this service. An appropriate diagnosis code was not billed. Based on this information, we decided that Medicare rules for coverage of the PET with CT scan services have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) services coded 78815 provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2740 x2), two core buildups, including any pins when required (D2950 x2), and two localized deliveries of antimicrobial agents (D4381 x2).

You asked the Plan to pre-approve the crowns, core buildups, and localized deliveries of antimicrobial agents. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered.

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 two crowns (D2740 x2), two core buildups, including any pins when required (D2950 x2), and two localized deliveries of antimicrobial agents (D4381 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided by a specialist.

You asked the Plan to waive the copayment for the specialist office visit. You say that you showed up for an appointment to receive scheduled treatment. While at the appointment, you were told that you actually needed care that could not be provided at the time. You do not believe you should have this copayment, because the provider's office made an error and your treatment had to be rescheduled. The Plan denied your request. The Plan says you had an office visit with a specialist on the date in question. An evaluation was provided. Specialist office visits are subject to a $35 copayment. The Plan also states that they are handling your dissatisfaction with the quality of services in a separate department.

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 $35 copayment for office visits provided by a specialist.

You have been asked to pay a $35 copayment for the specialist office visit. Medical records show that an evaluation was provided, and a treatment plan was discussed. This qualifies as an office visit. 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 the office visit (99214) provided by a specialist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology diagnostic services provided by a participating provider on September 17, 2020.

You asked the Plan to waive the copayment for radiology diagnostic services. You say that you feel like you should only have to pay a $15 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for outpatient diagnostic tests/radiological diagnostic services. 

You have been asked to pay a $100 copayment for radiology diagnostic services. The correct copayment has been applied to the services that were provided. Radiology diagnostic services fall within the outpatient diagnostic tests/radiological diagnostic services 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 radiology diagnostic services provided by a participating provider on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care.

You asked the Plan to waive the copayment for the inpatient care. You forwarded your bills to the Plan. The Plan denied your request. The Plan says each of the first six days of an inpatient hospital stay is subject to a $300 copayment. You were charged less than the full copayment because you met your out-of-pocket maximum during your care.

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 $300 copayment for each of the first six days of an inpatient hospital stay, with a $0 copayment for days beyond the first six.

You have been asked to pay a $857.48 copayment for the inpatient care. The Plan reached this decision by applying the $300 copayment to the first six days of your stay ($300 x 6 = $1800) and then capping your copayment once you hit the $3,400 out-of-pocket maximum for in-network 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 the inpatient care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on September 25, 2020.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, we have confirmed that code 74018 for the x-ray services has a bundled relationship with code 74340 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74018 provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 29, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says in order for medical services to be covered the enrollee must be received care from providers contracted with the Plan. The only exceptions to this are in cases of urgent or emergently-needed care, if the medical care required cannot be provided by contracted, in-network providers and the Plan has given prior authorization for such care or kidney dialysis services obtained at a Medicare-certified dialysis facility when you are temporarily outside the Plan's service area.

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 laboratory 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 laboratory services provided on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for inpatient mental health care provided February 22, 2021. We decided that the Plan does not have to pay for inpatient mental health care provided February 23, 2021, to discharge.

You asked the Plan to pay for inpatient mental health care provided February 22, 2021. You say that this service is medically necessary. The Plan says that inpatient mental health care is not medically necessary.

We decided that the Plan has to pay for inpatient mental health care provided February 22, 2021.

The Plan follows 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 pay for inpatient mental health care provided February 22, 2021. Our physician reviewer found that payment for the inpatient mental health care provided February 22, 2021 was warranted because the enrollee did require acute inpatient psychiatric hospitalization based on a noted dangerousness to self with records supervised and evaluated by a physician.

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 provided February 22, 2021 have been met. Therefore, we decided that the Plan has to pay for inpatient mental health care provided February 22, 2021.

We also decided that the Plan does not have to pay for inpatient mental health care provided February 23, 2021, to discharge.

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 inpatient mental health care provided February 23, 2021, to discharge. Our reviewer says that inpatient mental health care provided after February 23, 2021 was not medically necessary. Our physician reviewer found this patient does not meet criteria for acute inpatient mental health treatment after February 23, 2021, as this patient was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 

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 provided February 23, 2021, to discharge have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided February 23, 2021, to discharge.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevator.

You asked the Plan to pre-approve the seat elevator. You say that you need the items being requested for mobility and so that you can stay in your home. You say that the requested items are medically necessary. The Plan denied your request. The Plan says the item which remains in dispute is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that power seat elevation features and power standing features are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a seat elevator.