Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke and is living at home with frequent episodes of falling. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 additional fillings provided on January 13, 2021.
You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You say that this was the office you were able to walk to for services. You say that you are no longer able to drive. You also say that this was an emergency. The Plan denied your request. The Plan says 2 filling per calendar year are covered. The Plan also says that the frequency limit has been reached while processing this claim.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid the in network rate for 2 fillings that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the 2 additional fillings provided on January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic radiology test provided by a participating provider on January 26, 2021.
You asked the Plan to waive the copayment for a duplex scan. You say that you do not believe you should owe anything for this. 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 $50 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay a $50 copayment for a duplex scan. The correct copayment has been applied to the services that were provided. A duplex scan falls within the outpatient diagnostic tests/diagnostic radiology 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 a diagnostic radiology test provided by a participating provider on January 26, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can safely 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a tibial plateau fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on November 22, 2020.
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that freestanding ER services are only covered if the ER clinic is affiliated with a hospital. We looked at the file and Medicare rules. The file shows that the emergency room services were provided to the enrollee on November 22, 2020. This facility is considered a freestanding ER. This facility is not affiliated with a hospital. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on November 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of physical therapy.
You asked the Plan to pre-approve the continuation of physical therapy. The Plan denied your request. The Plan says both the short- and long-term goals have been met.
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 the continuation of physical therapy. 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. You appear to have improved with therapy for back and knee arthritis to the point of being able to manage basic activities of daily living and you were discharged from therapy services as of March 15, 2021. The medical records justifying the need for physical therapy for the shoulder are not provided. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of physical therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 5, 2020.

You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this type of provider is not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative EEG (95955) provided on December 30, 2019.
You asked the Plan to pay for the intraoperative EEG (95955). You say that the intraoperative EEG (95955) provided on December 30, 2019 was medically necessary. The Plan denied your request. The Plan says the intraoperative EEG (95955) provided on December 30, 2019 was not medically necessary.
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 pay for the intraoperative EEG (95955). Our reviewer says that the intraoperative EEG (95955) provided on December 30, 2019 was not medically necessary. Our physician reviewer found performance of electroencephalogram (EEG) (CPT 95955) during this type of surgery is not within the standard of care. Performance of EEG provides no clinical value/utility to the surgeon. Nor does it have any bearing on health outcomes. Furthermore, the CPT code billed has been used inappropriately. A two channel EEG falls significantly below the American Clinical Neurophysiology Society (ACNS) established technical standards for performance of EEG. Therefore, this code would not be 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 intraoperative EEG (95955) have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative EEG (95955) provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 7, 2021.

You asked the Plan to pay for the eye refraction. You say that a tech did this exam and not an ophthalmologist. You feel this exam should be covered. The Plan denied your request. The Plan says eye refractions are not covered by Medicare. The service was provided and billed as part of a medical eye exam and included a medical diagnosis. In addition, you signed a consent form with the provider's office on January 3, 2021 that acknowledged this refraction would not be covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided as part of a routine eye exam.

We looked at the file and the Plan's rules. The refraction was provided alongside medical eye exams and billed with a medical diagnosis. Generally, ophthalmologists or their technicians provide medical services. An optometrist deals with routine vision tests and eyewear prescriptions. In order for a refraction to be covered, it would need to be provided as part of a routine vision exam to evaluate the need for glasses or contacts due to a refractive (non-medical) diagnosis. The refraction in question was not routine. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on January 19, 2021.

You asked the Plan to reimburse you for the dental services. You say that when you made your appointment, you were advised that they accepted your insurance. You say that after your appointment, you were advised that they were not in network. You say that you were given incorrect information from your plan and the dental office. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that there is no record of a phone call prior to the date of service to verify benefits and provider eligibility.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services performed out of network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician services provided on December 28, 2020.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the Plan is the secondary payer.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment stating they are not the enrollee's primary insurer. However, the only documentation in the case file that shows the enrollee's plan coverage states the Plan is the primary insurer. The Plan did not provide any documentation to verify they are the secondary payer. Therefore, we decided that the Plan has to pay for the physician services provided on December 28, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says you do not have a change in function that needs daily skilled services on an inpatient basis.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 

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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for additional ambulance mileage (HCPCS A0888) received on September 19, 2020.
You asked the Plan to pay for the additional mileage. You say that this should be paid for. The Plan denied your request. The Plan says ambulance transportation is covered to the nearest appropriate facility.
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, the CPT Code Manual definition of HCPCS code A0888 is "Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)." We find that HCPCS code A0888 is not supported in the medical record. Specifically, the definition of this code indicates that it is not covered. Based on this information, we decided that Medicare rules for coverage of the additional mileage have not been met. Therefore, we decided that the Plan does not have to pay for additional ambulance mileage (HCPCS A0888) received on September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT capture with interpretation (D0367) provided on December 10, 2020.

You asked the Plan to pay for the dental service. You say that you have had recurrent problems with the tooth since the original root canal. You also say that you have been taking multiple antibiotics to keep the pain under control. The Plan denied your request. The Plan says cone beam CT capture with interpretation is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT capture with interpretation (D0367) provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on October 23, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing is not medically necessary.
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 pay for the testing. Our reviewer says that the requested /services are not considered medically reasonable and necessary in this case. Our physician reviewer found that FoundationOne Liquid CDx testing analyzes over 300 genes. The medical records in the case file consist of a Test Requisition Form, a Cytology report, and the testing results. The documentation does not support that the FoundationOne Liquid CDx testing was medically reasonable and necessary and will impact the management and outcome of the enrollee in this case. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on October 23, 2020.