Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that there is no clinical advantage of an LTACH over acute 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. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACH) 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. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the resin-based composites (D2331) provided on November 17, 2020.
You asked the Plan to pay the full amount for the resin-based composites. You say that this service should be completely covered because you had not met your $300 annual allowance. The Plan denied your request. The Plan says they have covered the full allowed amount for the resin composites. Per your Dental Rider, the Plan will only reimburse you for billed charges up to the maximum allowable amount for each service. You are responsible for any and all charges for dental services that exceed the maximum allowable amount.
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's supplemental benefit will only pay for services up to the Plan's allowed amount for each service. The record shows that the provider billed $154, but the Plan's allowed amount is $101 for the resin-based composites. According to your benefit, the remaining $53 which exceed the maximum allowed amount for this service or item are your responsibility. Therefore, we decided that the Plan does not have to pay the full amount for the resin-based composites (D2331) provided on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental healthcare hospital stay provided from March 26, 2020, to March 30, 2020.
You asked the Plan to waive the copayment for the inpatient mental healthcare hospital stay. You say that you received a statement saying you did not owe any money. You say now you owe $1,272 and you cannot make this payment. The Plan denied your request. The Plan says you have been asked to pay 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 $318 copayment per day, days 1 to 5 at an in-network inpatient psychiatric facility. You have been asked to pay a $318 copayment for each day of the inpatient mental healthcare hospital stay. ($318 x 4 = $1,272). The inpatient mental healthcare hospital stay falls within the "Inpatient mental health care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient mental healthcare hospital stay provided from March 26, 2020, to March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, panoramic x-ray, topical application of fluoride varnish, periodontal maintenance, and resin-based composite provided on October 9, 2020, and October 16, 2020.
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, topical application of fluoride varnish, periodontal maintenance, and resin-based composite. You say that you were advised that this provider accepted your insurance. You also say that you were told these services would be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective June 30, 2015, to June 30, 2021. The Plan also says that services performed by a provider who has opted out of Medicare cannot be covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. We looked the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation, panoramic x-ray, topical application of fluoride varnish, periodontal maintenance, and resin-based composite have not been met. Therefore, we decided that the Plan does not have
to pay for the periodic oral evaluation, panoramic x-ray, topical application of fluoride varnish, periodontal maintenance, and resin-based composite provided on October 9, 2020, and October 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for 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 was admitted for peripheral vascular disease and had left lower extremity bypass grafting. His medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 23, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was an annual wellness visit and everything you discussed was preventive. You say that you shouldn't have to pay $20. 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 $20 copayment for a primary care physician. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for diabetes, hypothyroidism and hyperlipidemia during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown for tooth #29 provided on September 30, 2020.
You asked the Plan to pay for the retainer crown for tooth #29. You say that you would like these services covered up to the $1,000 benefit. The Plan denied your request. The Plan says you reached your $1,000.00 maximum for the services received on September 30, 2020. The Plan also says that payment for dental services above the maximum of $1,000.00 cannot be issued.
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 $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the September 30, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the retainer crown for tooth #29 provided on September 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9379) provided from July 1, 2020, to July 31, 2020.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9379 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9379) provided from July 1, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refractions (92015) performed September 23, 2020.
You asked the Plan to pay for the refractions. You say that the services were medically necessary because you were purchasing glasses. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The plan provides coverage for one routine eye exam yearly, however, this service was not billed as a routine eye exam, therefore, the refractions are not a covered service. Therefore, we decided that the Plan does not have to pay for eye refractions (92015) performed September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab diagnostic services (81479) provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for this testing.

Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that outpatient diagnostic and lab services require prior authorization. The enrollee did not have prior authorization for this testing. Therefore, we decided that the Plan does not have to pay for lab diagnostic services (81479) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless pulmonary artery pressure monitoring system.
You asked the Plan to pre-approve a wireless pulmonary artery pressure monitoring system. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a wireless pulmonary artery pressure monitoring system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Cardiomems pressure sensing device implantation would be considered premature at this point in the absence of clear recurrent severe CHF while on optimal outpatient medical management. The Cardiomems pressure sensor monitoring device is therefore not medically necessary at this time based on the applicable CMS section 1862 medical necessity rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wireless pulmonary artery pressure monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless pulmonary artery pressure monitoring system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy procedure (45832) provided on June 12, 2020.
You asked the Plan to pay for a colonoscopy procedure. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be paid as billed.
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, we have confirmed that code 45832 has a Column One/Column Two relationship with code 45835 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a colonoscopy procedure (45832) provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria have not been met.
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 office visit to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on September 14, 2020.
You asked the Plan to pay for the anesthesia. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 14, 2020. The services in question were provided before the end of that month. Additionally, the record shows that you re-enrolled in hospice on September 17, 2020. Therefore, we decided that the Plan does not have to pay for the anesthesia provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor system.
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor system. You say that the item 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day sensor system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor system.
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 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 there are no services available at the LTACH that you require 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 your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential study coded 95938, the needle electromyography services coded 95861 and 95868, and the short-latency somatosensory evoked potential study coded 95927.
You asked the Plan to pay for the central motor evoked potential study, the short-latency somatosensory evoked potential study, the needle electromyography services, and the short-latency somatosensory evoked potential study.. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95939, 95938, 95861, 95868, and 95927 are not supported in the medical record. Specifically, the billed place of service, 15 (mobile unit) is not supported. The documentation submitted and/or claims data indicate the enrollee was an inpatient at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the central motor evoked potential study, the short-latency somatosensory evoked potential study, the needle electromyography services, and the short-latency somatosensory evoked potential study. have not been met. Therefore, we decided that the Plan does not have to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential study coded 95938, the needle electromyography services coded 95861 and 95868, and the short-latency somatosensory evoked potential study coded 95927.