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

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870). 

You say that you do not want to go through a major operation in a hospital followed by rehab. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental. More research is needed to show safety and efficacy of the devices.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2393) provided on March 11, 2021.

You asked the Plan to pay for the dental service. You say that you made several calls to the Plan to find an in network dentist in your area. You say that the providers that you were given were not accepting new patients. You also say that you had no choice but to go to your old dentist who is out of network. The Plan denied your request. The Plan says dental services performed out of network are not covered.

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, dental services performed out of network are not among those covered under this benefit. The record shows that while you did contact the Plan prior to the date of service, in network dental providers were not discussed. Therefore, we decided that the Plan does not have to pay for the filling (D2393) provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) provided on March 13, 2021.
You asked the Plan to pay for the ambulance response and treatment. You say that you fell, and your family members were not able to help you up. The police were called, and an ambulance was sent, but you did not feel you needed to go to the hospital. You say that you should not have to pay this bill because you did not want an ambulance and do not feel that one should have been sent to help you up. The Plan denied your request. The Plan says ambulance response and treatment without transport is not covered by Medicare or by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) provided on March 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care provided on October 25, 2020.
You asked the Plan to pay for the hospital care. You say that the patient was not in hospice on this date of service and the claim should be reconsidered. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 October 21, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital care provided on October 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an analysis of breast tumor tissue (81521) provided on March 11, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you received the tests from the ordering physician and was unable to obtain prior authorization. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The records provided for review also show that the enrollee was referred by a non-participating provider. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an analysis of breast tumor tissue (81521) provided on March 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for DME and related supplies provided on May 2, 2019.

You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for DME and related supplies. You say that you always pay your copayments at the time of the visit and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for DME and related supplies. 

You had a specialist visit on May 2, 2019. Therefore, you are responsible to pay the $10 copayment. 

You received DME and related supplies on May 2, 2019. The total allowed amount is $563.68 and 20% of that is $112.73. 

The total amount you owe is: $122.73.

You have been asked to pay the total amount of $122.73 for a specialist visit and DME and related supplies. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. DME and related supplies fall within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for DME and related supplies provided on May 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on January 28, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the surgical procedure was done outpatient. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $290 copayment for days 1-5 for inpatient hospital care. 

The record shows that you received inpatient hospital services on January 28, 2021. Therefore, you are responsible to pay the $290 copayment.

You have been asked to pay a $290 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided on January 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory (lab) testing provided on January 4, 2021.

You asked the Plan to pay for the lab testing. You say that the services were medically necessary. 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 enrollee'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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory (lab) testing provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a manual wheelchair purchased on December 21, 2020.
You asked the Plan to pay for the purchase of a manual wheelchair. You say that you feel the wheelchair should be covered. The Plan denied your request. The Plan says the item received is not a covered benefit when purchased.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment received must be rented in order to be covered. We looked at the file and Medicare rules. Review of the file shows that you purchased the wheelchair. The Plan only covers rented durable medical equipment. Based on this information, we decided that Medicare rules for coverage of the purchase of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a manual wheelchair purchased on December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD).
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an EGD is covered for the indications established in the applicable LCD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an EGD. Our reviewer says that the requested EGD is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has not had a recent colonoscopy. The record indicates that the enrollee previously required colon resection for a noncancerous lesion. The elements of the coverage criteria 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 an EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 ten (10) additional PT visits. 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 that based on review of the available records, the enrollee does not meet CMS coverage criteria for the requested continued services by a physical therapist with ten (10) additional visits. After twenty (20) PT visits this year, the enrollee made gains and at this point and the unique and sophisticated skills of a physical therapist are not required to continue to treat his condition. The enrollee has reached highest level of function realistically attainable and within the context of his disability with post-polio syndrome. The additional ten (10) PT visits are not reasonable and 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on March 11, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this was a pelvic exam screening and you should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

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. The Plan did not provide medical records in the case file. Without medical records we cannot determine whether or not services beyond a pelvic exam screening took place. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on March 11, 2021.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 2, 2021 to January 7, 2021.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted an incorrect bill type. This means the claim form does not have the appropriate home health data to process and pay the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 2, 2021 to January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing for 4 or more teeth per quadrant (D4341), and the scaling and root planing for 1 to 3 teeth per quadrant (D4342) provided on April 1, 2021.
You asked the Plan to pay for the dental services. You say that you should be reimbursed for the services. You also say that the bill has already been paid. The Plan denied your request. The Plan says scaling and root planing is not listed as a covered service. The Plan says that you did not contact the Plan prior to the date of service to verify benefits or 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, the scaling and root planing are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the scaling and root planing for 4 or more teeth per quadrant (D4341), and the scaling and root planing for 1 to 3 teeth per quadrant (D4342) provided on April 1, 2021.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.
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 physician reviewer found that in this case, the enrollee was admitted with a transmetatarsal wound dehiscence and leg cellulitis. He is receiving two antibiotics daily and does not have complex wound care needs. He continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride varnish application and periodontal maintenance provided on December 30, 2020.
You asked the Plan to pay for the fluoride varnish application and periodontal maintenance. You say that you had several hundred dollars on your plan, and you were informed you had enough to cover the December payment. You say that the benefits should not be denied. The Plan denied your request. The Plan says there is an annual maximum of $1,000 for dental services per year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $1,000 for dental services per year. The Plan paid $1,000 toward the dental services received from January 16, 2020, through December 30, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the fluoride varnish application and periodontal maintenance provided on December 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.

You asked the Plan to pre-approve proton beam radiation therapy. The Plan denied your request. The Plan says this 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 pre-approve proton beam radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that per NCCN radiation compendia, external beam and brachytherapy are only approved treatments. Proton beam radiation therapy is 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 proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you feel the enrollee should have been approved for short term rehabilitation services. The Plan denied your request. The Plan says the enrollee is lacking intensity of skilled or therapy needs.

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 the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. 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 a SNF admission.