Persius/hicric huggingface dataset:
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 the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 you do not require services at the LTACH that are not available at the acute care
hospital where you are 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 you require 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.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for otolaryngology services provided to the enrollee on
November 22, 2019.
You asked the Plan to pay for the services. You say that this should be reconsidered for payment. The Plan
denied your request. The Plan says with the current information, it cannot be determined how the enrollee came
to the servicing provider, or 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.
In this case, the CPT Code Manual definition of code 15733 is "Muscle, myocutaneous, or fasciocutaneous
flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter,
sternocleidomastoid, levator scapulae).
We find that CPT code 15733 is not supported in therecord. Specifically, despite three or more attempts to
obtain any form of clinical records, they still have not been received by the provider. There is no way to
determine if the services were medically necessary or even rendered. 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 otolaryngology services provided to the enrollee on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on March 5, 2020 by
an out-of-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you were never told an exact amount
as to what this brace would cost you. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2020 EOC 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).
Review of the file show that you received the DME on March 5, 2020. You have been asked to pay 20%
coinsurance of the allowed amount for DME. The allowed amount is $887.42. The total you owe is $180.75
($903.76 x 20% = $180.75). Your EOC states, "enrollees must pay 20% coinsurance for high cost DME and
related supplies." 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 the DME provided on March 5,
2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance services were necessary because there was no way that your husband could get you to the hospital. You say that you were unconscious when the ambulance arrived, and the responders had to administer an IV. You stated that you chose to not to be transported by the ambulance because you wanted to save the cost of the ambulance transport. You say that you do not think you should have to pay for the services since it would have cost the Plan more if you had been transported. You stated that you do not feel like you should be responsible for the ambulance and you asked the Plan to provide coverage. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 16, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for electroencephalogram (EEG) extended monitoring (CPT
95813) provided to the enrollee on July 23, 2019.
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 Current Procedural Terminology (CPT) code 95813 remains 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 95813 is "electroencephalogram (EEG) extended
monitoring; 61-119 minutes."
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
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT
95941 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or
nearby) or for monitoring of more than one case while in the operating room, per hour) would be a more
appropriate CPT code in this case.
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 electroencephalogram (EEG) extended monitoring (CPT 95813) provided to the enrollee on
July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora digital hearing aid (V5257-LT) provided to the enrollee on December 6,2019.You asked the Plan to pay fora digital hearing aid provided to the enrollee. You say that this claim should be paid.The Plan denied your request. The Plan says the records provided do not support the services billed.Medicare does not pay for hearing aids or related services. The Plan contract says that hearing aids are not covered. Code V5257is described as a digital hearing aid, which is not covered by Medicare or the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to Therefore, we decided that the Plan does not have to pay fora digital hearing aid (V5257-LT) provided to the enrollee on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine physical exam (99386) provided on March 17,
2020.
You asked the Plan to pay for the routine physical. You say that you would like reconsideration because you
were not satisfied with the first physical you received and were told by the Plan that this service would be
covered. The Plan denied your request. The Plan says although you were unsatisfied with the service you
received during your first physical, you chose to have a second physical done and you are responsible for full
cost.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the routine physical have not been met. Specifically, per the EOC, the Plan covers one routine
physical per year. The record indicates that you received a physical on March 2, 2020. Therefore, we decided
that the Plan does not have to pay for a routine physical exam (99386) provided on March 17, 2020.
Your complaint about being given incorrect information about this service 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: 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 you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says you can receive the services
you need in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies and it is not a reasonable expectation that you will be able to fully participate in
and benefit from the IRF 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. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on July
18, 2019.
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 supported by the documentation.
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 CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the
documentation does not support evidence of an established relationship between the enrollee and the ordering
physician. 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 80307 and
G0482 provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlift chair, with a seat lift mechanism and the sales tax purchased on December 21, 2019. You asked the Plan to pay forthe services. You say that you were advised that the cost of the chair would be covered and that you would be reimbursed 80%.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits and Medicarerules.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You were reimbursed 80% of the Medicare allowable for the seat lift mechanism per Medicare requirements. You are responsiblefor 20% coinsurance for the seat mechanism. The sales tax and the chair itself are not covered by Medicare. Your EOC states, "enrollees must pay 20% coinsurance for DME and related supplies." 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 pay forlift chair, with a seat lift mechanism and the sales tax purchased on December 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided March 3, 2020 to March 5, 2020.You asked the Plan to waive the copayment.You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.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 $150 copayment per day, for days 1-5and a $0 copayment after day 5, for inpatient hospital care. You have been asked to pay a $300 copayment ($150 x 2 days) for inpatient hospital care. 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 copaymentfor the inpatient hospital care provided March 3, 2020 to March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325) injections.
You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan
denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be
considered.
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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically necessary. Our physician reviewer found the record does not show the enrollee
had a failed trial of the plan preferred drugs, or that the plan preferred drugs would be unsafe or ineffective for
the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One (J7325) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea neuromuscular electrical stimulation (NMES) device.You asked the Plan to pre-approvethe NMES device. You say that based on the medical necessity guidelines it is clear that the intended application of the RT300 FES therapy system is medically appropriate and necessary to meet your basic health care needs.The Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria.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 NMES device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication for this specific device above standard TENS/electrical therapies. This is a convenience item, and deemed not 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 NMES device have not been met.Therefore, we decided that the Plan does not have to pre-approvea neuromuscular electrical stimulation (NMES) device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 11, 2020 through February 15, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not want to pay for the doctor at the emergency's room's mistake. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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). Review of the file shows that you were admitted on February 11, 2020 and discharged on February 15, 2020. You were asked to pay a $360 copayment per day from February 11, 2020 through February 14, 2020, days 1-4 of your inpatient hospital care. You were discharged on February 15, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $360 copayment per day required for days 1-5. 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 inpatient hospital care from February 11, 2020 through February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on June 27, 2019.You asked the Planto pay forthe drug testing. You say that this was medically necessary testing.The Plandenied your request. The Plansaysthere is no evidence that this provider is actively treating the enrollee for a specific medical condition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.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 Plandoes not haveto payforthe presumptive and definitive drug testing provided on June 27, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99214) provided October 7, 2019 to May 5, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the provider has opted out of Medicare and is not eligible for payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (99214) provided October 7, 2019 to May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 3,
2019.
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 supported by the documentation.
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 CPT code G0483 is not supported in the medical record. Specifically, the documentation does not
include a valid physician order/lab requisition form or medical records (signed by the ordering physician)
stating exactly what tests were to be performed. 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 December 3, 2019.