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

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 1, 2021.
You asked the Plan to pay for the screening test. You say that the test performed is valid. The Plan denied your request. The Plan says Medicare denies coverage of all cardiovascular risk assessment testing, except the basic lipid panel.
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 was requested solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the $34 copayment charged for chiropractic services provided on February 26, 2021.

You asked the Plan to reduce this copayment. You say that the Plan contract says that chiropractic services are only $20. The Plan denied your request. The Plan says for this visit there is a $20 copayment for manual manipulation and a $14 charge for physical therapy billed by your chiropractor that is not covered by Medicare in this setting. The Plan states the provider was contacted regarding this and states they will not resubmit the claim and remove the charge. The Plan states physical therapy by a chiropractor is not covered.

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 reduce the $34 copayment charged for chiropractic services provided on February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) thorax (71250) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the CT scan. You say that in order to provide continuity of care, it is important that the enrollee continue under this provider's care, which includes adhering to surveillance diagnostics including lab, imaging and lung function testing. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) thorax (71250) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair with seat lift function.
You asked the Plan to pre-approve the recliner. You say that you are in a lot of pain The Plan denied your request. The Plan says a recliner is not covered because it does not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a reclining chair with seat lift function
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs you received on October 7, 2020.

You asked the Plan to waive the coinsurance. You say that you were not told that you would have a cost share. The Plan denied your request. The Plan says you are responsible for the cost share.

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% coinsurance for Medicare-covered Part B prescription drugs. 

Review of the file shows that you were provided Part B drugs on October 7, 2020. You have been asked to pay a 20% coinsurance for the services, totaling $170.87. The services falls within the Medicare-covered Part B prescription drugs 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 coinsurance for the Part B drugs you received on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants with sedation and supplies.

You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental implants with sedation and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 13.
You asked the Plan to pre-approve the dental services. You say that your dental work has already begun. You say that you cannot chew well. You also say that this affects you other teeth too. The Plan denied your request. The Plan says there is a benefit maximum of $1,000 per year for comprehensive dental services. The Plan also says that the maximum benefit has been reached.
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 and crowns are listed as covered, the maximum benefit has been reached.
Claim #
CPT Code
Tooth #
Plan Paid
21050E015284
D2940
13
$27
21137E003410
D0460
13
$20
21137E003445
D3320
12
$377
21137E003445
D3320
13
$377
21147E004349
D2954
12
$100
21147E004349
D2954
13
$100
TOTAL:
$1,001
Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adolescent dentition (D8080).

You asked the Plan to pre-approve the braces. You say that all of your income goes to payment for your assisted living facility. You say that you will never be able to afford braces for your lower teeth. You say that your condition is painful. You also say that you struggle to eat. The Plan denied your request. The Plan says comprehensive orthodontic treatment of the adolescent dentition is not listed as a covered service.

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 comprehensive orthodontic treatment of the adolescent dentition is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adolescent dentition (D8080).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve eight (8) additional PT visits. You say that you have continued difficulty with activities requiring right hip strength and you have gained function during therapy and would like to complete your progress with additional therapy. The Plan denied your request. The Plan says eight (8) additional PT visits are not medically 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 eight (8) additional PT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been authorized two (2) more PT sessions to ensure competence and transition to an independent home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your 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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Home Health
Decision: Unfavorable

CWe decided that the Plan does not have to pre-approve the HHA services (G0156). 
 
You asked the Plan to pre-approve the HHA services. The Plan denied your request. The Plan says you do not 
meet Medicare rules for HHA services. 
 
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 the HHA services. Our reviewer says 
that associated HHA services are not shown to be medically necessary, reasonable or coverable. Our physician 
reviewer found there is no evidence that you are receiving home health registered nursing services or home 
health rehabilitative 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 the HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve the HHA services (G0156)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital care.

You asked the Plan to pre-approve this service. You say that inpatient psychiatric hospital care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient psychiatric hospital admission.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 this service. Our reviewer says that inpatient psychiatric hospital care is not medically necessary. Our physician reviewer found that the enrollee was admitted for an acute inpatient psychiatric hospitalization on July 30, 2021 with Major Depressive Disorder, recurrent, severe without psychotic features and a Major Neurocognitive Disorder most likely due to Alzheimer's Disease without behavioral disturbance. Based upon a review of the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the date in question as he was not showing any dangerousness to self or others, there were no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and did not have any side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the date in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. This enrollee does not require inpatient mental health treatment beyond the date in question. It does not appear that the services requested for the date in question were reasonably expected or medically necessary to improve the patient's condition or were for the purpose of a diagnosis. Based upon review the records provided, this patient does not meet the criteria for acute inpatient mental health treatment beyond the date in question of August 5, 2021. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine non-emergency transportation trips.
You asked the Plan to provide coverage for additional routine non-emergency transportation trips. You say that you have seizures, and you are a diabetic and require frequent physician's visits for monitoring. The Plan denied your request. The Plan says additional routine non-emergency transportation trips are not covered.
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 40 one-way trips per year.
We looked at your request, the records in the case file, and the rules. 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 provide coverage for additional routine non-emergency transportation trips
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an infectious disease office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist visit. You say that the enrollee's infectious disease team recommended that he return to the group that started his plan of care. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an infectious disease office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical or manipulative therapy performed for maintenance rather than restoration (S8990x8).
You asked the Plan to pre-approve the chiropractic services. You say that you believe keeping a maintenance schedule of chiropractic spinal manipulation has helped you keep these painful episodes to a minimum, so you are requesting to have your insurance cover your chiropractic maintenance schedule. The Plan denied your request. The Plan says S8990 is not a Medicare approved chiropractic code. Covered CPT codes include 98940, 98941 or 98942 for chiropractic manipulative treatment 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 pre-approve physical or manipulative therapy performed for maintenance rather than restoration (S8990x8).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an elective right Total Knee Arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you will need to stay at the hospital for recuperation because no one will be able to take care of you at home. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 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 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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that you are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the CMS Inpatient Only List. The procedure is currently approved as an outpatient procedure. There is no documentation provided to support the expectation that you will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician would reasonably expect that your necessary hospital care (including earlier ED and/or observation care) will span two midnights. We looked at this physician's review, 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. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an elective right Total Knee Arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs speech, physical therapy, and occupational therapy so that he can get back on his feet. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee was admitted following being found down most likely secondary to hypoglycemic seizure. The enrollee is gradually improving. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee