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

We decided that the Plan does not have to pre-approve a laminectomy (63047) for lumbar decompression.
You asked the Plan to pre-approve a laminectomy. You say that this is medically necessary. The Plan denied your request. The Plan says you are not enrolled in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that lumbar decompression will be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. The record does not show that you are enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of a laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a laminectomy (63047) for lumbar decompression.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions and 2D oral/facial image provided on February 19, 2020.
You asked the Plan to pay for the oral hygiene instructions and 2D oral/facial image. You say that you didn't ask for an x-ray or any other kind of service. You say that they should have checked with the Plan to make sure the services were covered. The Plan denied your request. The Plan says the services are not covered benefits.
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 oral hygiene instructions and 2D oral/facial image provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the blood pressure monitor provided on January 17, 2020.You asked the Plan to pay for the blood pressure monitor. You say that your doctor recommended that you check your blood pressure daily at home.The Plan denied your request. The Plan says that this device is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the blood pressure monitor by a contract provider. The file does not show that the Plan provided notice that the blood pressure monitor would not be covered. Under Medicare rules, this means the blood pressure monitor is considered approved by the Plan.Therefore, we decided that the Plan has to pay for the blood pressure monitor provided on January 17, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forretreatment of previous root canal therapy (D3348) provided March 13, 2020.You asked the Plan to pay forthe dental services. You say that this was medically necessary because you had developed aninfection where the root canal had been previously done.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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. Services not listed under the description of benefits is not covered by the plan.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 forretreatment of previous root canal therapy (D3348) provided March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve the requested wheelchair. You say that you are dragging and hitting your feet. The Plan denied your request. The Plan says adjustments were made to the enrollee's group 2 wheelchair to improve safety.
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are only covered under certain medical indications. 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 requested wheelchair. Our physician reviewer found that the documentation does not indicate that you are unable to perform a functional weight shift; or utilize intermittent catheterization for bladder management, or that you are requesting this seating system to manage increased tone or spasticity. A power seat elevation feature and power standing feature are non-covered because they are not primarily medical in nature. Therefore, the requested power wheelchair and related accessories are 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 the requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient depression screening services provided March
10, 2020.
You asked the Plan to pay for the depression screening services. You say that you are appealing because you
do not understand the billing issue. Your doctor would not have approved it if you didn't qualify. The Plan
denied your request. The Plan says this service exceeds the benefit frequency limitation.
The Plan must follow Medicare rules. Medicare rules say that Screening for depression is non-covered when
performed more than one time in a 12-month period. The records show that a depression screening was
provided February 10, 2020. Therefore, this benefit is exhausted.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the depression screening services have not been met. Therefore, we decided that the Plan does not
have to pay for the outpatient depression screening services provided March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for epidural injections provided on January 28, 2020.
You asked the Plan to pay for the epidural injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the actual date of service cannot be verified therefore the billed service cannot be verified.
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 the procedure date on the medical record is different than the submitted claim date of service. Therefore, the primary code is illegible for payment as well as the add-on code. Based on this information, we decided that Medicare rules for coverage of the epidural injections have not been met. Therefore, we decided that the Plan does not have to pay for epidural injections provided on January 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedic intercept services provided on December 22, 2019.You asked the Plan to pay forthe paramedic intercept services. You say that the Plan should pay this claim.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 pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that provided the transport services.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services provided on December 22, 2019
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required maximum assistance for bed rolling, sitting up, lying down, standing up and bed to chair transfers. The enrollee was non-ambulatory at this time. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient mental health services (99213) provided March 13, 2020.You asked the Plan to waive the copayment forthe outpatient mental health services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $35 copayment for Therapy Visits. You have been asked to pay a $35 copayment for the outpatient mental health services. The outpatient mental health services fall within the Therapy 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 foroutpatient mental health services (99213) provided March 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance transport (A0429) provided March 26, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls 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 foran ambulance transport (A0429) provided March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the stair lift provided on November 19, 2019.
You asked the Plan to reimburse you for the stair lift. You say that this is an expensive item that helps get you
up and down the stairs. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to reimburse you for the stair lift provided on November 19,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport (A0428) provided January 2, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $220 copayment for Ambulance Services. You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls 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 for the ambulance transport (A0428) provided January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient hospital services (82565, 93970, 84520, 3641) provided July 31, 2019.You asked the Plan to waive the copayment forthe outpatient hospital services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 outpatient hospital visits. You have been asked to pay a $211.75 copayment for the outpatient hospital services. The outpatient hospital services falls within the outpatient hospital visits benefit category. In this case, the Medicare allowed amount is less than the $250 noted in the plan contract. 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 foroutpatient hospital services (82565, 93970, 84520, 3641) provided July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.You asked the Plan to waive the copayment for the ambulance services. You say that you are in a nursing home and have no extra funds to pay this invoice and would hope this can be removed from being collected.The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $275 for these services. 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.
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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to acute care on 7/5/20 after presenting to the emergency department with acute dysphasia and hand clumsiness. The enrollee was admitted to ICU and began to have additional symptoms, Stat stroke called and TPA was administered. He has residual expressive aphasia, and upper limb clumsiness. He is working with therapy. He is hemodynamically stable. CT scan since admit (abdomen) showed possible diverticulitis. He is non-toxic and minimal assist mostly, for activities of daily living 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, skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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: 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 the member's current needs are being met in the 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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alginate dressings.
You asked the Plan to pre-approve the alginate dressings. You say that the records provided support the need for the dressings requested. The Plan denied your request. The Plan says the enrollee's wound is draining but it is not full thickness stage 3 or 4 wound.
The Plan follows Medicare rules. Medicare rules say that alginate or other fiber gelling dressing covers and fillers are covered for moderately to highly exudative full thickness wounds and wound cavities. 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 alginate dressings. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records provided do not show that the enrollee has a full thickness (stage III or IV) wound cavity. 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 alginate dressings have not been met. Therefore, we decided that the Plan does not have to pre-approve alginate dressings.