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

We decided that the Plan does not have to pay forAdacel immunization injection (90715) performed on July 16, 2020.You asked the Plan to pay forAdacel immunization injection. You feel that this immunization should be included in your wellness visit.The Plan denied your request. The Plan says rules for payment have not been met.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Adacel immunization injection. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to Adacel immunization injection.Therefore, we decided that the Plan does not have to pay forAdacel immunization injection (90715) performed on July 16, 2020.Benefits for Adacelimmunization injectionmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal right
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 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 the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for repair of a hip fracture after a fall. Medical problems are stable. There are no identified problems
that need inpatient medical management. 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 medical record supports a need for physical and occupational
therapy but it does not support a need for an intensive rehabilitation therapy program. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0676).

You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis after knee replacement.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676).
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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a seizure and was treated for a urinary tract infection and pneumonia. Medical problems are stable. There are no identified problems that need inpatient medical management. Thereare 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 medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe revision of total hip arthroplasty services coded 27138 and the arthrotomy with synovectomy services coded 27054 provided on March 10, 2020.You asked the Plan to pay forthe revision of total hip arthroplasty services and the arthrotomy with synovectomy 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 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 27138 and 27054 are not supported in the medical record. Specifically, the operative report did not include documentation of a revision of a total hip arthroplasty, for the femoral component only, with or without allograft; therefore, code 27138 cannot be verified. The operative report did not include documentation of arthrotomy with synovectomy, of the hip joint, as a separate procedure; therefore, code 27054 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the revision of total hip arthroplasty services and the arthrotomy with synovectomy services have not been met.Therefore, we decided that the Plan does not have to pay forthe revision of total hip arthroplasty services coded 27138 and the arthrotomy with synovectomy services coded 27054 provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from April 29, 2020, to May
13, 2020 other than manual manipulation of the spine.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says Medicare and the Plan only cover services directly related to manual
manipulation of the spine.
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 chiropractic services provided from April 29, 2020, to May 13, 2020 other
than manual manipulation of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovethe Continuous Glucose Monitoring System (CGM).You asked the Plan to preapprovethe CGM. You say that you require this device because of issues you experience with current test strips.The Plan denied your request. The Plan says you are not receiving daily injections and therefore do not meet coverage criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to preapprovethe Continuous Glucose Monitoring System (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forintermittent limb compression device.You asked the Plan to pay forintermittent limb compression device. You say that the device is necessary.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for when the documentation does not reflect that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessaryfor the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay forintermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formolecular genetic hereditary predictive screening testing provided to the enrollee on January 30, 2020.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit. The review has determined that the requested molecular genetic hereditary predictive screening testing provided to the enrollee on January 30, 2020 were 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 testing have not been met.Therefore, we decided that the Plan does not have to pay formolecular genetic hereditary predictive screening testing provided to the enrollee on January 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the filling (D2391) for tooth # 21, and the filling (D2393) for tooth # 28 provided from December 10, 2019, to February 17, 2020.You asked the Plan to pay forthe dental services. You say that you chose to see this provider because they were the least expensive. You also say that the services should be covered.The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says fillings are not listed as covered services either.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 forthe limited oral evaluation (D0140), the filling (D2391) for tooth # 21, and the filling (D2393) for tooth # 28 provided from December 10, 2019, to February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 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. Your medical status does
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple
therapies such as physical and occupational therapy but the documentation does not support that your high
functional level requires an 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you are not strong enough to be released from the facility to the memory center.The Plan denied your request. The Plan says that the members needs are custodial in nature.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 therequest 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 continued 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-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) physical therapy visits (CPT Code 97164).
You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the patient's condition. The patient has had prior therapy for this condition and it does not appear that the patient's deficits require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been authorized an additional session to further review an independent exercise program which is already versed and compliant in. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) physical therapy visits (CPT Code 97164).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel that the copayment should be waived because the enrollee had COVID and that was the reason for the ambulance trip to the hospital. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
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 $240 copayment for each ambulance trip. You had 40 ambulance trip(s). The Plan charged you $240 for these 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 ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied 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 the patient does not appear to require complex wound care and his acute care treatment is nearly complete. Continued acute care can be safely completed in the current setting. The patient does not require services at the LTACH that are not already available at the current setting. There are no services at the current setting that the patient requires that are not already available and covered at the current setting. Therefore, transfer to LTACH is not supported and will be considered not medically necessary at this time. Consideration for transfer to a lower level of care may be made soon.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-approveLTACH services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient telemedicine specialist visit (99213) provided July 15, 2020.
You asked the Plan to waive the copayment for the telemedicine services. You say that you only had a 3 minute conversation with the doctor and he did nothing for you. You feel that you should not be responsible for the copayment. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the 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). Your contract with the Plan clearly says that you must pay $40 copayment to specialists per visit. You have been asked to pay $40 copayment for the telemedicine services. The telemedicine services fall within the Physician/practitioner services, including doctor's office visits 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 the outpatient telemedicine specialist visit (99213) provided July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services billed to the enrollee via telehealth services on May 14, 2020.You asked the Plan to pay forthis claim. You say that this claim should be paid.The Plan denied your request. The Plan saysthe provider, located in Lakeland, FL, ordered laboratory testing via telemedicine for this enrollee located in Hialeah, FL, approximately 220 miles away, which is a Medicare prohibited action.Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system.The services billed are not covered. 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 claim submitted cannot be paid as billed when originating from a telehealth visit. Based on this information, we decided that Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forlab services billed to the enrollee via telehealth services on May 14, 2020.