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

We decided that the Plan does not have to pay for the home health services rendered from January 19, 2021 to
January 28, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with a valid HIPPS code.

We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid HIPPS
code. Based on this information, we decided that Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from
January 19, 2021 to January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 3, 2021.

You asked the Plan to waive the copayment for specialist services. You say that this doctor was not a specialist. You say that this doctor just does the remote monitoring The Plan denied your request. The Plan says the correct copayment has been 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 $25 copayment for physician/practitioner services/in-network/specialty care physician.

You have been asked to pay a $25 copayment for specialist services. The provider who provides adjustment
and monitoring is considered a specialist; therefore, the correct copayment has been applied. Specialist services
fall within the physician/practitioner services/in-network/specialty care physician 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 specialist services provided by a participating provider on March 3,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound, abdominal aortic, real time with image documentation, screening study for abdominal aortic aneurysm (76706) provided December 20, 2019.
You asked the Plan to pay for the diagnostic service. You say that the staff indicated that they had reviewed your insurance and you were pre-approved for the procedure and there would be no copay. The Plan denied your request. The Plan says the claim was reprocessed with the correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that the plan has a one-time (once per lifetime) screening ultrasound for people at risk.
You have been asked to pay $979 for the diagnostic service. Per the Evidence of Coverage, abdominal aortic aneurysm screening can only be performed one time (once per lifetime). The records show that this service was already performed November 2, 2018. Therefore, the benefit for this is exhausted. The diagnostic service falls within the Abdominal Aortic Aneurysm Screening 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 pay for the ultrasound, abdominal aortic, real time with image documentation, screening study for abdominal aortic aneurysm (76706) provided December 20, 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 IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 25, 2021.

You asked the Plan to pay for the orthoses. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address Coronavirus concerns. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, and the supplier is not enrolled/certified with Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trifecta allograft (20930).
You asked the Plan to pre-approve the Trifecta allograft. You say that this request is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the requested procedure has not been
demonstrated as effective in the peer-reviewed literature for the enrollee's condition.
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 the Trifecta allograft. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee is 57-year-old male who is being treated for cervical spondylosis. He
presents with pain that radiates from his left shoulder area around the trapezius and down his anterior left chest.
He also gets numbness down his left arm, and pain with trying to lift/activity with using the left arm.
There is some right-sided tingling, but not as much. Exam reveals limited neck range of motion with some
discomfort. Spurling's is positive. There is no significant weakness with grip strength, finger spread, wrist
flexion/extension of the upper extremities. There is pain that radiates from his trapezius down to the left
anterior chest (as his main area that bothers him with pain.) The requested C5-7 anterior cervical discectomy
and fusion has been approved for coverage.
However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request for
the Trifecta allograft to be an effective and/or safe treatment for the noted pathology. There is no compelling
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an
exception to guidelines. Therefore, the request for Trifecta allograft (20930) is not medically reasonable or
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 Trifecta Allograft have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Trifecta allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided
by a participating provider on November 11, 2020, to November 18, 2020.

You asked the Plan to waive the copayment for inpatient rehabilitation services. You say that you do not agree
with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $310
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/innetwork.

You have been asked to pay a $310 copayment per day for days 3-6. There is a $0 copayment for additional
days for inpatient rehabilitation services. The total amount you are being asked to pay is $1,240 ($310 x 4 days
= $1,240). The first two days as an inpatient are not included in this claim. Inpatient rehabilitation services fall
within the inpatient hospital care/in-network 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 inpatient rehabilitation services provided by a participating provider on November 11, 2020, to November
18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve the inpatient hospital admission. You say that the enrollee's pain is
worsening, and she has a declining quality of life. You say that the records provided support the level of care
being requested. The Plan denied your request. The Plan says there is no documentation to support the
expectation that the enrollee will require a greater than 2 midnight stay. The Plan say that if the enrollee
experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be
performed on concurrent review with updated clinical information.

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 pre-approve the inpatient hospital admission. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the record indicates that the enrollee is scheduled for a reverse shoulder
arthroplasty. The provided records do not indicate that the treating physician has a reasonable expectation of a
length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of
the coverage rule are not satisfied.

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 inpatient hospital admission have not been met. Therefore, we decided that
the Plan does not have to pre-approve an inpatient hospital admission.
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 enrollee meets the full IRF criteria based on Medicare guidelines. You say that the enrollee's needs cannot yet be safely met by home health. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.

The Plan must follow Medicare rules. The rules say that 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for altered mental status. The enrollee's medical conditions are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The
enrollee does require physical and occupational therapy but there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a
reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2), the partial upper denture (D5213), and the partial lower denture (D5214) provided on February 6, 2021.

You asked the Plan to pay for the dental services. You say that you had these services done with your current provider who is in network. You say that the plan is not being approved based on the county that you reside in, from your understanding. You also say that you feel that this may have been a genuine mistake. The Plan denied your request. The Plan says the dental services performed are not covered. The Plan also says that they will pay the difference between the billed amount and the amount on the pre-service agreement of $634.55 to honor the pre-service agreement with the contracted provider.

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 record shows that you signed a pre-service agreement with the contracted provider in this case. The file shows that the Plan elected to make partial payment for these services to ensure that you do not owe more than what you agreed to pay the provider prior to the services being rendered. You are responsible for the amount that was agreed to on the pre-service agreement, $1092.22. Therefore, we decided that the Plan does not have to pay more for the scaling and root planing (D4341 x 2), the partial upper denture (D5213), and the partial lower denture (D5214) provided on February 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on November 15,
2019.

You asked the Plan to pay for the emergency department visit (99285). You say that the claim was timely. The
Plan denied your request. The Plan says the claim was submitted untimely.

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 emergency department visit (99285) was not filed until December 9,
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 emergency department visit provided on
November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on November 4, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. 
The Plan denied your request. The Plan says you have exhausted the allowable benefit for this service, this calendar year.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection, milrinone lactate, 5 mg (J2260) supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) (A4221) infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222)

You asked the Plan to pay for the infusion supplies. You say that please see attached copy of the medical records and signed orders by the physician. The Plan denied your request. The Plan says the billed supply code 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 proof of delivery, or an itemized shipping/billing invoice to indicate the specific supplies. 

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 injection, milrinone lactate, 5 mg (J2260) supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) (A4221) infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222)
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services coded as 97110, 99072, 97140 provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physical therapy services. You say that please review all documentation included in this request and kindly approve the services for payment, as these services were medically necessary. 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physical therapy services coded as 97110, 99072, 97140 provided on February 9, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation
(D0150) provided on February 25, 2020.

You asked the Plan to pay an additional amount for a comprehensive oral evaluation. You say that the service
at issue should be covered. The Plan denied your request. The Plan says the provider was paid at the Medicare
allowed rate therefore no additional payment can be made.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation have not been met. Specifically, the allowed amount of this
service for an out-of-network provider was paid by the plan. Therefore, we decided that the Plan does not have
to pay an additional amount for a comprehensive oral evaluation (D0150) provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture reline provided on August 6, 2018.
You asked the Plan to pay for the complete upper denture reline. The Plan denied your request. The Plan says the maximum allowed for the calendar year has been met.
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, you also have a maximum benefit of $1,500 for dental services per year. The Plan says $1,500 was paid toward dental services prior to receiving the denture reline, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture reline provided on August 6, 2018.