Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health care services.You asked the Plan to pre-approvehome health care services. You say that the requested home health care services are medically necessary.The Plan denied your request. The Plan says the requested home health care services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health care services. Our reviewer says that the requested home health care services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The documentation does not reveal that the enrollee is homebound. Additionally, the documentation does not reveal that skilled services are needed. The services do not meet the definition of home health aide services as per Section 50.2 and home health aide services are not reasonable and necessary to thetreatment of the enrollee's illness or injury by the skilled professional staff.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health care services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admissionto a LTACH is not medically necessary. 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 she is 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.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forchiropractic services (CPT 99203, HCPCS G0283) received .You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are limited chiropractic benefits, and this service is excluded.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 Plandoes not haveto pay forchiropractic services (CPT 99203, HCPCS G0283) received
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 23andMe genetic testing.

You asked the Plan to pre-approve the 23andMe testing. You say that you would like reconsideration because this testing is medically necessary due to your conditions. The Plan denied your request. The Plan says this testing is not considered medical genetic testing and is not covered by Medicare.

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, the 23andMe testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 23andMe genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe occlusal guard provided .You asked the Plan to pay more forthe occlusal guard. You say that this should be covered under your medical coverage because it was due to a medical injury.The Plan denied your request. The Plan says the maximum $500 benefit has been met for the2020 benefit year. The Plan also says that this service was not provided due to any non-routine dental care.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 Plan offers a combined benefit maximum of $500 per calendar year for the non-Medicare-covered preventive services. Once the dental services you receive reach the $500 benefit maximum, you will be responsible for paying any remaining costs of supplemental dental services. The record shows that you met the annual maximum benefit while processing this claim for the date of service and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay more forthe occlusal guard provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit provided .You asked the Plan to pay forthe domiciliary or rest home visit. You say that  The Plan denied your request. The Plan says that the Plan has topay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 domiciliary or rest home visit. 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 fora domiciliary or rest home visit provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. 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 she is 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.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for10mg Prochlorperazine tablets.You asked the Plan to pay for10mg Prochlorperazine tablets. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not being used as a full therapeutic replacement for IV anti-emetic drugs that would have been administered at the time of the chemotherapy treatment.The Plan must follow Medicare rules. Medicare rules say that the oral anti-emetic drugsprovided must be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10mg Prochlorperazine tablets have not been met. Specifically, the record indicates that this drug is not being used as a full therapeutic replacement for IV anti-emetic drugs that would have been administered at the time of the chemotherapy treatment.Therefore, we decided that the Plan does not have to pay for10mg Prochlorperazine tablets.Benefits for 10mg Prochlorperazine tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided .You asked the Plan to waive the copayment forthe ambulance services. You say that you feel you should notbe responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received ambulance services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 copayment for Ambulance services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance services . You have been asked to pay a $250 copayment for the ambulance services. The ambulance services fall 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 services provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visits (99213) urinalysis (81002) provided .You asked the Plan to waive the copayment forthe office visit. You say that you are writing to complain about the additional charges in addition to your co-pay for office visits that you were never notified about at the time for servicesThe Plan denied your request. The Plan says the claim was processed and the correct copayment has been applied per the Evidence of Coverage.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 $50 copay for each Medicare covered specialist visit.You have been asked to pay $50 copay for the office visit. The office visit falls 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 forthe outpatient office visits (99213) urinalysis (81002) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have pain in both of your feet from knots. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided .You asked the Plan to waive the copayment forlaboratory services. You say that you paid $12 for the original lab work and are receiving another bill. You say that this should have been covered with the original charge.The Plan denied your request. The Plan says the copayment applied 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 $12 copayment for Medicare-covered lab tests.You have been asked to pay a $12 copayment for the laboratory services. Laboratory services fall 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 forlaboratory services provided
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered .You asked the Plan to pay forthese services. You say that youdisagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessaryfor the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 that 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 wasadmitted for a surgical repair of a hip fracture after a fall. His medical problems are stable. There are nocomplex nursing or rehabilitation needs. The patient doesnot 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.Thereis not a reasonable expectation that the 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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does nothave to pay forinpatient hospital admission following an elective total shoulder arthroplasty.You asked the Plan to pay foracute inpatient hospital care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not necessary.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 acute inpatient hospital care have not been met. The procedure iscurrently approved as an ambulatory procedure. 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 inpatientlevel of care can be performed on concurrent review with updated clinical information.Therefore, we decided that the Plan does not have to pay forinpatient hospital admission following an elective total shoulder arthroplasty
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 18 and 29.

You asked the Plan to pre-approve the dental services. You say that the crowns are necessary. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 plan years. The Plan also says that the frequency limit has been exceeded.

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 of once per tooth every 5 plan years has been reached. The record shows that the Plan paid for a crown for tooth # 18 that the enrollee received on July 31, 2018. The record shows that the Plan paid for a crown for tooth # 29 that the enrollee. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 18 and 29.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care at an out of network facility.

You asked the Plan to pre-approve continued care at an out of network facility. You say that the continued care at the out of network facility is medically necessary. The Plan denied your request. The Plan says the continued care at the out of network facility is not medically necessary as there are in-network providers available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.

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 continued care at an out of network facility. Our reviewer says that the continued care at the out of network facility is not medically necessary as there are in-network providers available. Our physician reviewer found the out-of-network provider states that the enrollee recently had a mammogram that detected a lesion suspicious for breast cancer and that these lesions need biopsy to confirm diagnosis, which they scheduled. The out-of-network provider feels that switching physicians now will significantly delay the course of treatment for the enrollee. The out-of-network provider does not feel that the in-network providers offered by the health plan have the expertise to detect the lesions found and feel that they would have been missed.

Based on the documentation provided, the enrollee can be managed safely by the in network providers available. The requested out of network provider is 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 continued care at an out of network facility have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care at the out of network facility.