Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 12, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the comprehensive oral evaluation had to be done in order to diagnose your problems correctly. You also say that you were not advised by the provider ahead of time that this procedure would not be covered. The Plan denied your request. The Plan says this service is not covered by your health plan or by Medicare. 
 
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 comprehensive oral evaluation (D0150) provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter, per week (A4221), infusion supplies for external drug infusion pump, per cassette or bag (A4222) and injection, milrinone lactate, 5 mg (J2260) provided to the enrollee from October 8, 2019 through October 14, 2019.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.

Healthcare Common Procedure Coding System (HCPCS) code A4221 (1 Unit) remains not supported. The documentation submitted did not include valid order for the billed date of service to support the billed code; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.

Healthcare Common Procedure Coding System (HCPCS) code A4222 GA (7 Units) remains not supported. The documentation submitted did not include valid order for the billed date of service to support the billed code; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.

Healthcare Common Procedure Coding System (HCPCS) code J2260 (41 Units) remains not supported. The documentation submitted did not include valid order for the billed date of service to support the billed code; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter, per week (A4221), infusion supplies for external drug infusion pump, per cassette or bag (A4222) and injection, milrinone lactate, 5 mg (J2260) provided to the enrollee from October 8, 2019 through October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forportable oxygen concentrator purchased on February 24, 2020 from an out-of-network provider.You asked the Plan to pay forportable oxygen concentrator. You say that you were told that you could use your out-of-network benefits for the purchase of a portable oxygen concentrator.The Plan denied your request. The Plan says their Customer Service Team advised you that there was only coverage for rentals and not purchases on August 10, 2019. The Plan states on January 27, 2020, you called asking about coverage for a portable oxygen concentrator from the provider and you were advised to obtain CPT codes and call back to determine coverage. ThePlan states on February 24, 2020, you called asking if it was okay to use you out-of-network benefits for oxygen DME and you were told that you could use out-of-network benefits for DME. The Plan further states that there was no mention of you asking about purchasing the DME from the out-of-network supplier.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Review of the file show that you purchased a portableoxygen concentrator on February 24, 2020 from an out-of-network provider. The Medicare rules state, "only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered."Therefore, we decided that the Plan does not have to pay forportable oxygen concentrator purchased on February 24, 2020 from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care on August 6, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid for date of service August 6, 2019. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. With the information we have, we cannot determine the progression from observation to requiring inpatient service. All providers are required to furnish necessary information to the Plan when requested. The provider's staff is responsible for submitting information to the Plan for review and determination. After three or more attempts to obtain information, none was received as of this date. Therefore, we decided that the Plan does not have to pay for inpatient hospital care on August 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you would like torequest a reconsideration of the Plan's denial of emergency ambulance services. You say that you were out of town and unable to get to your doctor when you fainted. You stated that when you fainted, the place of business you were in called for an ambulance. You say that the responders checked your blood pressure and other vitals, however you were not transported to the hospital. You stated that you suffer from hypertension and diabetes and you asked the Plan to reconsider providing payment for the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 1, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve continued physical therapy services. You say that the enrollee would benefit from continued physical therapy. The Plan denied your request. The Plan says the enrollee can be independent with a home program. 
 
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 continued physical therapy services. 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 records show that the enrollee has had extensive therapy for this condition and participates in a home exercise program. The documentation does not indicate his functional deficits need the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design, or deliver a program to maintain the enrollee'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 continued physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on April 2, 2020.
You asked the Plan to pay for the intraoral x-ray. You say that you needed the service for an emergency tooth
extraction. The Plan denied your request. The Plan says the service is only allowed once per calendar year.
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 also has a maximum benefit
amount of one intraoral-complete series OR panoramic film every 36 months. The records show that you
received the service on January 7, 2020 which exhausted your benefit. Therefore, we decided that the Plan does
not have to pay for the intraoral x-ray provided on April 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid purchased on December 15, 2018. 
 
You asked the Plan to pay for the hearing aid. You say that you were not aware that you had coverage for hearing aids until a coworker advised you of the benefit. The Plan denied your request. The Plan says you submitted the claim to the Plan more than twelve (12) months after you purchased the hearing aid. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hearing aid was not filed until May 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hearing aid purchased on December 15, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the abdomen (74183).You asked the Plan to pre-approvean MRI of the abdomen. You say that the service is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the abdomen. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the submitted records, the criteria for medical necessity of an MRI of the abdomen are not met. Specifically, no imaging reports such as ultrasound etc. are included to provide any indication for MRI. No abnormal lab results are included and the last encounter of April 6, 2020 failed to provide an indication for same.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the abdomen have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the abdomen (74183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion
catheter (A4221) IV pole (E0776) provided October 22, 2019 to October 28, 2019.
You asked the Plan to pay for infusion supplies. You say that please see the attached additional documentation
and reprocess for payment. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter
(A4221) IV pole (E0776) provided October 22, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) renderedby the out of network (OON) provider on September 11, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was renderedby an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) rendered by the out of network (OON) provider on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colostomy supplies provided from January 21, 2020 to April 8, 2020. 
 
You asked the Plan to waive the coinsurance for the colostomy supplies. You say that you should not be charged because these were Medicare approved supplies. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered prosthetic and orthotic device supplies.  
 
You have been asked to pay a 20% coinsurance for the colostomy supplies. The colostomy supplies fall within the Medicare-covered prosthetic and orthotic device 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 coinsurance for the colostomy supplies provided from January 21, 2020 to April 8, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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 enrollee was admitted 7/5/2020 following a fall, and subsequent femoral neck fracture. He underwent surgery with titanium nail fixation on 7/9/2020. Now, he is afebrile and hemodynamically stable. He is full weight bearing, but moderate/maximum for transfers and care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drug (aspirin) provided on February 28, 2020.You asked the Plan to pay forthe aspirin. You say that you have looked through your Evidence of Coverage, and can find no reason this procedure was not covered. You also say that your cardiologist requested pre-approval, and you do not understand why the payment has been denied.The Plan denied your request. The Plan says self-administered drugs are not covered by your plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare PartB.Therefore, we decided that the Plan does not have to pay forthe self-administered drug (aspirin) provided on February 28, 2020.Benefits for the aspirinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 appears to be improving, however, is not stable enough for discharge. It doesn't appear that the enrollee will likely require at least an additional 25 days of acute care before being stable for discharge to a skilled nursing facility. The enrollee does not appear to require services at the proposed LTACH that are not already available at the current acute care hospital. If additional acute care is needed, they could be administered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Continued care in the current setting, then transfer to a lower level of care in the near future appears most appropriate based on the provided documentation.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered
medically reasonable and necessary in this case.
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 was admitted to the acute care hospital following heart valve and bypass
surgery. He was diagnosed with respiratory failure and required mechanical ventilation. He required antibiotics
and hemodialysis. He still requires assistance with ventilation and PEG tube feeds and now has a tracheostomy.
He was able to tolerate transition to pressure support/CPAP for 3 hours. Leukocytosis was improving and vitals
stabilizing. He requires ongoing Bumex drip, physical therapy and monitoring. Creatinine is worsening and
anemia worsening. Based on the provided recent records, clinical status is varying from day to day with some
improvement in some areas but others not stable enough for discharge. Ongoing acute care is required and can
be continued in the current location. The enrollee does not require services at the LTACH that are not available
at the current acute care hospital. Therefore, this request for LTACH services appears to be not medically
necessary as he is not stable for discharge and is already receiving appropriate care.
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.