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

We decided that the Plan does not have to waive the copayment forthe ambulance transportation services (A0426, A0398, A0425) provided .You asked the Plan to waive the copayment forthe ambulance transportation. You say that you did not choose to ride in an ambulance. You say you drove yourself to the emergency room and the hospital decided to transport you via ambulance to another facility for more adequate treatment.The Plan denied your request. The Plan says ambulance services were provided and require a $260 copayment.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 $260 copayment for ambulance services.You have been asked to pay a $260 copayment for the ambulance transportation. Ambulance transportation falls within the ambulance 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 forthe ambulance transportation services (A0426, A0398, A0425) provided
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial hospital care provided .You asked the Plan to pay forinitial hospital care. You say that the Plan should pay this claim.The Plandenied your request. The Plan says the medical records submitted were for a different day of service.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 99223 is Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99223 is not supported in the medical record. Specifically, there are no medical records in the case file for this date of service. Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinitial hospital care provided
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered  .You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 51728 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 51728 is complex cystometrogram (i.e., calibrated electronic equipment); with voiding pressure studies (i.e., bladder voiding pressure), any technique.We find that CPT code 51728 is not supported in the medical record. Specifically, there is no detailed report of a complex cystometrogram with voiding pressure studies. 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 forthe surgical services rendered .
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower seat elevation and attendant control (CPT code (s) E2300 and E2331).You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says the DME is not necessary.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You have beneficiary controls and the power seat is never covered for any reason at all. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.Therefore, we decided that the Plan does not have to pre-approvepower seat elevation and attendant control (CPT code (s) E2300 and E2331).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 complexity of the enrollee's nursing, medical and rehabilitation needsdoes not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute respiratory failure, acute metabolic encephalopathy, acute renal failure, and a renal stone. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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-approveacute IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (CPT code D3310).

You asked the Plan to pre-approve the dental services. You say that you had an accident, and fell and broke two (2) teeth. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. The service is not a covered benefit under the plan. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (CPT code D3310).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission following an elective left knee arthroplasty.

You asked the Plan to pre-approve inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The Plan states there is NO documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. The Plan states there is NO documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission following an elective left knee arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the partial removal of kidney using an endoscope (50543) provided on March 2, 2020.

You asked the Plan to waive the deductible for the surgical procedure. You say that you are unsure of what you owe and what your actual cost-share responsibility is for the services you were provided. The Plan denied your request. The Plan says that as of the date of this service, you had not met your deductible yet. Outpatient surgery requires that the deductible be met before the Plan will pay their share of the cost. Therefore, the $152.34 you were billed for this service was applied to your deductible.

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 $1000 deductible for outpatient surgery. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the surgical procedure was received on March 2, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the partial removal of kidney using an endoscope (50543) provided on March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; with contrast material(s) (CPT code 71260).

You asked the Plan to pre-approve the CT scan. You say that the scan is necessary. The Plan denied your request. The Plan says the CT scan is not indicated and would be very low yield.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

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 CT scan. Our physician reviewer found the review of the medical documentation indicates that the enrollee has a cough and their provider thinks it may be related to the enrollee's sinuses. The reason this request cannot be approved is because: Guidelines support a chest x-ray prior to considering a chest CT for the evaluation of a cough. The clinical information provided does not describe these results and, therefore, the request is not indicated at this time. The review has determined that the requested CT Scan is not medically reasonable or 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax, diagnostic; with contrast material(s) (CPT code 71260).
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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 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-approve LTACH services.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Eylea 2MG/0.05ML (CPT code J0178), for the enrollee.

You asked the Plan to pre-approve the medication. You say that Eylea should be approved for enrollee's diagnosis of active exudative age-related macular degeneration in the enrollee's right eye. You state Avastin is not appropriate as it is not FDA approved for wet ARMD and has a higher rate of permanent floaters. The Plan denied your request. The Plan says that there is no indication the enrollee has experienced therapeutic failure or intolerance after a trial with one plan-preferred medication (Avastin (for ophthalmic use), and no progress notes have been submitted to show that the plan-preferred medication(s) is/are not clinically appropriate for the enrollee to try at this time.

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 the medication. Our physician reviewer found the enrollee has not tried and failed the required drug. However, the retinal specialist documents that the enrollee is failing treatment with Lucentis. Lucentis is a compound that is related to Avastin, and shares a similar mechanism of action. Consequently, it is likely that Avastin would be less effective and/or would have adverse effects for the enrollee 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 medication have been met. Therefore, we decided that the Plan has to pre-approve Eylea 2MG/0.05ML (CPT code J0178), for the enrollee.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical information they received did not support the medical necessity of the service requested.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 22, 2020.

You asked the Plan to pay for the dental service. You say that bitewing x-rays were not covered under your old plan. You say that you were in the process of switching to a higher plan which started on November 1, 2020. You also say that the bitewing x-rays should be covered under the new plan that you upgraded to. The Plan denied your request. The Plan says bitewing x-rays are limited to 1 set every plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that claims are processed within the year that they are incurred, under the policy that is in effect for the date of service, of when services were rendered.

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 frequency limit for bitewing x-rays has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on February 27, 2020. Additionally, the record shows that the claim for this date of service was processed under the plan that that was in effect on the date of service. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a diagnostic colonoscopy provided by a participating provider on October 23, 2020.

You asked the Plan to waive the deductible and copayment for a diagnostic colonoscopy. You say that that this copayment is way too high. The Plan denied your request. The Plan says the correct copayment and deductible 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 $250 deductible and a $350 copayment for outpatient surgery/outpatient hospital. 

You have been asked to pay a $250 deductible and a $350 copayment for a diagnostic colonoscopy. The total amount you are being asked to pay is $600 ($250 deductible + $350 copayment = $600). A diagnostic colonoscopy falls within the outpatient surgery/outpatient hospital 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 deductible and copayment for a diagnostic colonoscopy provided by a participating provider on October 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve forty-right (48) additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation to critically timed hyperbaric treatments. The Plan denied your request. The Plan says you exhausted your benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at your request, the records in the case file, and the rules. The 25th trip and beyond is not a covered benefit. The health plan contract says up to twenty-four (24) one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve forty-right (48) additional routine transportation trips.