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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says an inpatient level of care is not medically necessary. An observation level of care can be approved.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.
Our physician reviewer found you have a medical history significant for arthritis, fibromyalgia, degenerative disc disease, chronic fatigue syndrome, multiple chemical sensitivities. You presented to the emergency department (ED) on April 3, 2021 for complaints of non-radiating substernal left-sided chest pain, that started 3 days prior. You stated that the pain was worse with movement and lifting heavy objects. You reported starting to be active and lifting heavy weights. You denied associated palpitations, shortness of breath, lightheadedness, and diaphoresis. You denied having a cough, fever, chills. You denied smoking, alcohol, recreational drugs. While in the ED, your blood pressure was noted to be 167/110, and you were given clonidine and Lisinopril. You were admitted to telemetry care. Your condition stabilized and improved, and you were discharged home with outpatient follow-up the following day. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower partial denture (D5212), a complete upper denture (D5110), and a panoramic radiographic image (D0330) provided on March 18, 2021.
You asked the Plan to pay for a lower partial denture, a complete upper denture, and a panoramic radiographic image. You say that you were frustrated trying to find an in-network provider, so you decided to have services done out-of-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture, a complete upper denture, and a panoramic radiographic image have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a lower partial denture (D5212), a complete upper denture (D5110), and a panoramic radiographic image (D0330) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (93306) provided to the enrollee on April
2, 2021.
You asked the Plan to pay for echocardiography. You say that this should be paid for. The Plan denied your
request. The Plan says payment for this service is the responsibility of the 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 code 93306 is "Echocardiography, transthoracic, real-time
with image documentation (2D), includes M-mode recording, when performed."
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 echocardiography. Our reviewer says that
the services at issue in this case were not supported by the medical records. Our physician reviewer found the
record indicates that the enrollee underwent echocardiography (93306) on April 2, 2021. The enrollee
underwent the requested service as part of chemotherapy management. The requested service is not eligible for
payment to another provider or supplier other than the performing 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 echocardiography have not been met. Therefore, we decided that the Plan does
not have to pay for echocardiography (93306) provided to the enrollee on April 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided December 18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you disagree with the 
copayment because you were transported to a different hospital for surgery. The Plan denied your request. The 
Plan says the copayment has been 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 a $220 
copayment for each one&#8209;way Medicare&#8209;covered ground ambulance trip  
You have been asked to pay a $220 copayment for the ambulance transport. This service falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) 
provided December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with interpretation (D0364), the pulp vitality test (D0460), the consultation (D9310), and the unspecified preventive service (D1999) provided on April 15, 2021. You asked the Plan to pay for the dental services. You say that you had a root canal. You say that you lost your vision right after. You also say that you feel that these services should be covered under your medical benefit. The Plan denied your request. The Plan says the services in this case are dental in nature. The Plan says that routine dental services are not covered by Medicare. The Plan also says that these services are not listed as covered services under the supplemental dental benefit.
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. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with interpretation (D0364), the pulp vitality test (D0460), the consultation (D9310), and the unspecified preventive service (D1999) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection rendered on January 22, 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 procedure code S0020 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code S0020 (injection, bupivicaine hydrochloride, 30 ml) has a status indicator of I and is not valid for Medicare purposes. 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 bupivicaine hydrochloride injection rendered on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee is overweight and a fall risk. 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 pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine and administration provided on April 8, 2021.
You asked the Plan to pay for the Tdap vaccine and administration. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation shows you received the vaccination as a preventative measure which means it is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine and administration. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine and administration provided on April 8, 2021.
Benefits for the Tdap vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on July 9, 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 procedure codes 81162, 81164, and 81293 are not covered.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code cannot be paid regardless of whether a modifier is used. The provider submitted a claim for procedure codes 81162 (BRCA1 testing, full sequence analysis and full duplication/deletion analysis), 81163 (BRCA1 testing, full sequence analysis, DNA repair associated), and 81164 (BRCA1 testing, full sequence analysis, full duplication/deletion analysis). Codes 81163 and 81164 are column II codes with a modifier indicator of 0 when billed with column I code 81162. Payment for codes 81163 and 81164 is not allowed. The provider submitted a claim for procedure codes 81292 (MLH1 gene analysis, full sequence analysis) and 81293 (MLH1 gene analysis, known familiar variants). Code 81293 is a column II code with a modifier indicator of 0 when billed with column I code 81292. Payment for code 81293 is not allowed. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray, cone beam CT image capture and incomplete endodontic therapy provided on March 22, 2021.
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray, cone beam CT image capture and incomplete endodontic therapy. You say that you were never informed your dental did not roll over to the new plan year. You say that you sought the dental care you needed thinking the work would be covered. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray, cone beam CT image capture and incomplete endodontic therapy provided on March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can continue to receive appropriate intensive rehabilitation
services at the inpatient rehabilitation facility until he is ready to safely return to the home or community-based
environment. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on July 20, 2020.
You asked the Plan to pay for the services provided. You say that medical records were provided for review. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. We find that the testing was done without any abnormal findings. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need more days for inpatient rehabilitation as you are not strong enough. You state you have fallen and have a bouncing knee which is hurting and making it difficult for you to walk. You state without the rehabilitation your quality of life will decline and you will not be able to go home knowing that you are strong enough to walk and keep your balance. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for vaginal candidiasis and cellulitis and were discharged to a skilled nursing facility on July 17, 2021.
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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone.
You asked the Plan to pre-approve Oxycodone. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat diagnostic medial branch blocks.
You asked the Plan to pre-approve repeat diagnostic medial branch blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered for certain indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve repeat diagnostic medial branch blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back with facet joint tenderness but also with radicular symptoms to the feet. The enrollee takes Diclofenac, Tramadol and Amitriptyline for pain. The enrollee had diagnostic medial branch blocks and had 5-6 weeks of 70% pain relief. The level of pain relief did not reach 80% pain relief criteria and the enrollee has ongoing radiculopathy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat diagnostic medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat diagnostic medial branch blocks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular testing services provided on 
December 31, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The testing services were requested for screening purposes. There are 
insufficient medical records to show the results of the testing would be used  to determine a specific diagnosis 
or treatment strategy. Medicare does not cover this testing for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the hereditary cardiovascular testing services provided on December 31, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have extreme knee issues and you are unable to get up quickly to get to the restroom. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.