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

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Chest (71250). You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee is noted to have a history of pulmonary nodules. These nodules were shown to be stable fromNovember 2016 to January 2019. There is no evidence of new or worsening respiratory signs or symptoms. There is no evidence of new or worsening findings on a CXR. Therefore, the requested CT scan of the chest is not shown to be medically necessary or reasonable.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 Computed Tomography (CT) of the Chest (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 29, 2020.
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 medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee has weakness, knee and hip pain, and recurrent falls. A physician progress note dated June 2, 2020 states she is not able to wash clothes, cook, and is having a hard time getting out of bed. A June 16, 2020 physical therapy visit demonstrates she needs minimal to contact guard assist for bed mobility and modified assist for transfers and ambulation. Her current medical status does not require intensive physician or nursing oversight in an IRF. She may benefit from further therapy but does not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forosseous surgery (D4261) provided June 13, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you completed treatment because you were told the policy was not an HMO and that the services would be covered under your Plan PPO fees, which you are in in-network PPO provider.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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. The health plan contract specifically says care rendered by a provider that is not part of the Plan's supplemental dental network is not covered.Though the Plan offers a dental benefit in excess of Medicare coverage, the requesteditems or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forosseous surgery (D4261) provided June 13, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on February 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were paid on a separate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to services previously paid by the plan by the same provider for the same date of service. Duplicate claims are not payable. 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 the services (CPT 71045) provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forinfusion supplies (HCPCS A4223) provided to the enrollee from October 29, 2019 to October 31, 2019.You asked the Plan to pay forthe supplies. You say that this should be paid for.The Plan denied your request. The Plansays this code has a status indicator of X.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 HCPCS code A4223 is "Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)."We find that HCPCS code A4223 is not supported in the medical record. Specifically, this code has a status indicator of "X" which means it is statutorily excluded from coverage. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plan does not have to pay forinfusion supplies (HCPCS A4223) provided to the enrollee from October 29, 2019 to October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested admission to a SNF.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care for pneumonia and status post fall secondary to weakness. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a contact guard to minimal assist level with functional mobility including gait to short distances with a rolling walker. The beneficiary required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided to the enrollee on January 13, 2020.
You asked the Plan to waive the copayment. You say that you did not know the copayment would be so high. The Plan denied your request. The Plan says the cost share applied appropriately.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for Medicare-covered diagnostic radiology services. Review of the file shows that the enrollee had an MRI on January 13, 2020. The enrollee has been asked to pay a $275 copayment for the services. The services fall within the outpatient diagnostic services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided to the enrollee on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
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 LTACHs do not provide clinical advantage over a non LTACH acute care
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 enrollee is currently undergoing treatment at an ACH following surgery for a
small bowel obstruction that was complicated by a wound infection. The enrollee is not intubated/ventilated.
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can
then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided June 24, 2019.
You asked the Plan to pay for the ambulance transportation. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transportation. Our reviewer says that ambulance transportation was not medically necessary. Our physician reviewer found the enrollee was not bedbound, as evidence by her ability to sit, transfer and ambulate. The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair van) without endangering the enrollee's condition. 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 ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered on December 1, 2017.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are part of the surgical procedure because they were performed by the same physician.The Plan must follow Medicare rules. The rules say that anesthesia procedures are bundled into the surgical payment when performed by the same position.We looked at the file and Medicare rules. The file shows that the same physician billed procedure code 00840 for anesthesia and the surgical procedure. Payment for the anesthesia is therefore included in the surgical procedure.Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered on December 1, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on December 5, 2019.
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 procedure code J0280 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 J0280 is injection, aminophyllin, up to 250 mg.
We find that CPT code J0280 is not supported in the medical record. Specifically, there is no documentation of
three units of 25 milligrams of aminophylline. 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
injection rendered on December 5, 2019.
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 based on the enrollee's improvement, the enrollee's condition is stable and suitable for transfer to LTACH. You say the enrollee cannot be adequately care for in his current condition in a SNF. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH. The services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 that based on the documentation provided the enrollee is currently undergoing treatment at an ACH for newly diagnosed colon cancer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on February 10, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you were referred to this periodontist by your dentist. You also say that there were no participating periodontists near you and the Plan said you could see this out-of-network provider. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on February 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from May 4, 2019 to May 6, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided from May 4, 2019 to May 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency medical transportation.
You asked the Plan to pre-approve the non-emergency medical transportation. The Plan denied your request. The Plan says there are no additional transportation benefits available once it is exhausted.
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. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used 24 of the allowed 24 trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve non-emergency medical transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on February 6, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the diagnosis was not billed correctly.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, a chest x-ray, was requested solely for screening purposes. Medicare does not coverthis test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on January 20, 2020. You asked the Plan to waive the copayment for an ECG. You say that you have not been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 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 $30 copayment for non-radiological diagnostic services. You have been asked to pay a $30 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ECG provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from January 6, 2020 to January 31, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $20 copayment. for in-network physician specialist services. You have been asked to pay a $20 copayment for each of the specialist office visits. The specialist office visits 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 copayments for the specialist office visits provided from January 6, 2020 to January 31, 2020.