Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT) code 97530) provided to the enrollee on September 2, 2020.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.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 services. Our physician reviewer found the enrollee was treated by a certified occupational therapy assistant for an abnormal gait and weakness. The billing code did not reflect this level of care and the documentation did not support that the enrollee had been evaluated by a skilled therapist.
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 services have not been met.Therefore, we decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT) code 97530) provided to the enrollee on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed with side rails and trapeze bar.You asked the Plan to pre-approve the semi electric hospital bed with side rails and trapeze bar. You say that the hospital bed is needed due to the enrollee's advanced Parkinson's disease. You say that the enrollee's symptoms include severe motor fluctuations in addition to freezing episodes. You say that this further complicates the enrollee's ability to get into bed and turn and change positions while in bed. You say that the enrollee also requires assistance getting in and out of bed.The Plan denied your request. The Plan says the items in dispute are not medically necessary.The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met:1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have been considered and ruled out; or4. The patient requires traction equipment, which can only be attached to a hospital bed.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 semi electric hospital bed with side rails and trapeze bar. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation indicates that enrollee's diagnosis of Parkinson's disease complicated by paranoia and hallucination did not meet criteria for a hospital bed with side rails and trapeze bar. Member requires assistance to change position which can be accomplished in a regular bed. The review has determined that a hospital bed is not medically necessary for this patient. The side rails and trapeze bar are not medically reasonable or necessary We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the semi electric hospital bed with side rails and trapeze bar have not been met.Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed with side rails and trapeze bar.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel A panel constitutes a single procedural service, so one code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on February 5, 2021.

You asked the Plan to pay for the eyeglasses. You say that you were told by the provider that the eyeglasses would be covered. The Plan denied your request. The Plan says the eyeglasses and frames are a non-covered item. Per the enrollee's benefits, there is no coverage for extended eye wear outside of the cataract benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eye wear.

The services you asked the Plan to pay for are considered routine eye-wear. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on September 29, 2020.You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plan does not have to pay for the transportation services provided on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 81479, 82955) provided on May 29, 2020.
You asked the Plan to pay for laboratory services. You say that these tests were medically necessary. The Plan denied your request. The Plan says these tests were not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 81479, 82955) provided on May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Abdomen and pelvis (74177) and chest (71260).

You asked the Plan to pre-approve the CT scans. You say that the CT scans are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scans. Our reviewer says that the CT scans are not medically necessary. Our physician reviewer found CT scans to look for distant metastatic disease are not indicated for a patient with stage 1 rectal cancer treated with trans-anal excision and are not endorsed by NCCN as standard 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 the CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Abdomen and pelvis (74177) and chest (71260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound supplies provided on November 6, 2020.

You asked the Plan to pay for the wound supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items are not payable as billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order for the supplies provided in this case. The documentation submitted did not include a physician's order to indicate the specific supplies for the billed date of service. The submitted signed order is dated December 4, 2020, but the billed date of service is November 6, 2020. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wound supplies provided on November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 3, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) received December 30, 2020.

You asked the Plan to pay for the periodontal scaling and root planing. You say that the requested service was necessary. The Plan denied your request. The Plan says your benefit for this procedure was exhausted on this date of 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. The Plan covers the periodontal scaling and root planing when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. The Plan has submitted evidence that reimbursement was previously issued for these procedures on dates of service August 28, 2019 and September 12, 2019. Your benefit for
periodontal scaling and root planing was exhausted on December 30, 2020. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) received December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine surgery.You asked the Plan to pre-approve a spine surgery. 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 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 a spine surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found smoking is a contraindication to spine fusion surgery. You are a smoker and there is not test results in the records showing smoking cessation.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 spine surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve a spine surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheoplasty for the enrollee.
You asked the Plan to pre-approve this tracheoplasty for the enrollee. You say that this procedure is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules specifically deny the requested code and procedure as non-covered. Therefore, we decided that the Plan does not have to pre-approve tracheoplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213, 85025, 80053, 83036, 84439, 84443,
84153, 82306, 84481, 82670, 84144, 84402, 82627, 82530, 11981, J7999) provided on February 8, 2021, by a
provider that has opted-out of Medicare.

You asked the Plan to pay for an office visit. You say that this provider has been covered in the past. The Plan
denied your request. The Plan says services from opt-out providers are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office
visit (99213, 85025, 80053, 83036, 84439, 84443, 84153, 82306, 84481, 82670, 84144, 84402, 82627, 82530,
11981, J7999) provided on February 8, 2021, by a provider that has opted-out of Medicare.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need the requested transportation trips to get to dialysis and other doctor appointments. The Plan denied your request. The Plan says the number of trips being requested exceeds your benefit allowance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way routine transportation trips per calendar year.
We looked at your request, the records in the case file, and the rules. The records show that you have already received coverage for the 60 allowed routine transportation trips in the 2021 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 100 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, pulp vitality tests, or pay for the simple extraction, retainer crown provided on October 15, 2020, and November 24, 2020 by an OON provider.

You asked the Plan to pay more for the problem focused limited oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, pulp vitality tests, and to pay for the simple extraction, and retainer crown. You say that you believe that these services should be covered. The Plan denied your request. The Plan says the retainer crown is not a covered service. The Plan also says that the services processed and paid according to your elected plan 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 retainer crown is not among those covered under this benefit. The EOC says that you have a $150 annual deductible for OON dental services, which was applied toward the extraction. The EOC also says that you are responsible for a 20% coinsurance for each service that is received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, pulp vitality tests, or pay for the simple extraction, retainer crown provided on October 15, 2020, and November 24, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF from June 19, 2021, forward.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF from June 19, 2021, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Botox. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Dysport or Xeomin before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there is no documentation that the patient
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This
enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified
therapist are required to safely and effectively provide medically necessary and reasonable treatment.
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.