Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee has low potassium levels, hepatitis, and shortness of breath. You say that the enrollee needs LTACH services because his needs cannot be met in a lower level of care. The Plan denied your request. The Plan says LTACH services are not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and only requires short-term additional acute care services until more stable that can be safely received at the current facility until ready for discharge to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered soon when the enrollee is more stable and when treatment has completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy (97802) provided December 16, 2020.
You asked the Plan to pay for medical nutrition therapy services. You say that this request was medically necessary. The Plan denied your request. The Plan says this not a covered service for your condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy (97802) provided December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), oral hygiene instructions (D1330), and an unspecified preventive procedure (D1999) provided on March 23, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, oral hygiene instructions, and an unspecified preventive procedure. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. Oral hygiene instructions, and an unspecified preventive procedure 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.
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, oral hygiene instructions, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on March 10, 2021. Additionally, oral hygiene instructions, and an unspecified preventive procedure are not covered services. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), oral hygiene instructions (D1330), and an unspecified preventive procedure (D1999) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy, 45 minutes (CPT code 90834) provided on January 29, 2021, by an out-of-network provider.
You asked the Plan to pay for the psychotherapy. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 psychotherapy, 45 minutes (CPT code 90834) provided on January 29, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided March 26, 2021, to March 30, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you believe the number of days you received inpatient care should be reconsidered.The Plan denied your request. The Plan says the copayment processed correctly in this case.

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 inpatient hospital care. You have been asked to pay a total cost share of $1000 for the inpatient hospital care services you received (4 days inpatient x $250 copayment). This service falls within the inpatient hospital care benefit category. 

In this case, you are not being charged for the day you were discharged. Furthermore, although you are disputing the charge for the day you were admitted, this processed correctly. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided March 26, 2021, to March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is necessary. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee can remain at the current acute care hospital (ACH) until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee improved on bi-level positive airway pressure (BiPAP) in the hospital. There is no documented failure of BiPAP used as an outpatient when stable. Certain BiPAP devices can provide the AVAPS-AE mode of support that has been ordered. Medicare does not pay for a ventilator when used as BiPAP. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on November 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that in-network providers do not require a referral. The Plan denied your request. The Plan says there are contracted physicians who can provide the care 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 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 evaluation and management services provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept at L5-S1 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided September 4, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you went to the hospital and had your stitches taken out and went back to work. No other services were performed. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 you must pay $90 for each Medicare covered emergency room visit for Emergency care. You have been asked to pay $90 for the emergency visit. The emergency visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on December 7, 2020.
You asked the Plan to pay for a shower chair. You say that you cannot safely assist your mother in the shower without this transfer shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 pay for a shower chair provided on December 7, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging and regadenoson injection provided on October 15, 2020.
You asked the Plan to waive the cost for the myocardial perfusion imaging and regadenoson injection. You say that you thought this was going to be covered from the notifications being sent out. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 per day for Medicare-covered diagnostic radiology services (such as CT, PET, MRI, and nuclear cardiac imaging) and 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay a total of $197.35 for the myocardial perfusion imaging and regadenoson injection.
Service
Allowed Amount
Standard Cost
Member Liability
Myocardial Perfusion Imaging
$534.45
$150
$150
Regadenoson Injection
$236.76
20%
$47.35
TOTAL:
$197.35
The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The regadenoson injection falls within the "Medicare Part B prescription drugs" benefit category. The Plan says the cost for these services was not included in the cost share waiver. 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 cost for the myocardial perfusion imaging and regadenoson injection provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a filling (D2392), a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an unspecified preventive procedure (D1999 x2), and sales tax (D9985 x2) provided from February 8, 2021, through February 17, 2021.
You asked the Plan to pay an additional amount for a filling, a comprehensive oral evaluation, a teeth cleaning, an unspecified preventive procedure, and sales tax. You say that you want the Plan to pay an additional amount for these services. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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 filling, a comprehensive oral evaluation, a teeth cleaning, an unspecified preventive procedure, and sales tax have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Additionally, an unspecified preventive procedure, and sales tax are not covered benefits. Therefore, we decided that the Plan does not have to pay an additional amount for a filling (D2392), a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an unspecified preventive procedure (D1999 x2), and sales tax (D9985 x2) provided from February 8, 2021, through February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on November 16, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the services were not billed with appropriate diagnosis codes. 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 subsequent hospital care rendered on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a complete upper denture (D5110), and a panoramic radiographic image (D0330) provided on December 2, 2020.
You asked the Plan to pay an additional amount for a complete upper denture, and a panoramic radiographic image. You say that you want the Plan to pay an additional amount towards the services at issue. 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 complete upper denture, and a panoramic radiographic image have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a complete upper denture (D5110), and a panoramic radiographic image (D0330) provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on March 2, 2021.
You asked the Plan to pay an additional amount for a limited oral evaluation, and an extraction. You say that you could not find a network provider for the services you needed. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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 limited oral evaluation, and an extraction have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on March 2, 2021.