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

We decided that the Plan does not have to pay for the ambulance services provided on November 10, 2020.

You asked the Plan to pay for the ambulance services. You say that you had fallen and the medics assisted you getting back up. 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 ambulance services when there is no transport. 

The ambulance company did not provide transport services on November 10, 2020. 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 the ambulance services provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided October 22, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed using the correct CPT code.
The Plan must follow Medicare rules. Medicare rules say that Medicare requires use of CPT 81479 to report Next-Generation genetic sequencing. We looked at the file and Medicare rules. A Guardant360 molecular pathology genomic profiling was performed. This procedure must be reported using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided October 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency, wheelchair van transportation (A0130) provided on November 18, 2020.
You asked the Plan to pay for the non-emergency, wheelchair van transportation (A0130). You say that you needed this type of transport because you require 24-hour oxygen. The Plan denied your request. The Plan says non-emergency ambulance is excluded from coverage.
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 non-emergency, wheelchair van transportation (A0130) provided on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services beyond June 7, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that it is felt that the enrollee would benefit from continued care in the SNF. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of 6/7/2021 the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. The member received skilled care and improved; however, his functional improvement had plateaued by 6/7/2021, and he did not require any further inpatient skilled rehab services. The member's function was at or near his new baseline and he could be discharged to a lower level of care for further services. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 6/7/2021. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services beyond June 7, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the private duty nursing services rendered on June 11, 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 code T1000 is not supported.
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 T1000 is private duty / independent nursing service(s) -
licensed, up to 15 minutes.
We find that CPT code T1000 is not supported in the medical record. Specifically, the records do not support the billing of 76 units of this code. 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 private duty nursing services rendered on June 11, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoral periapical first x-ray (D0220) provided January 5, 2021You asked the Plan to pay forthe dental services. You say that the office never informed you, nor was it given permission to perform any service that was above and beyond the scope of your insurance coverage. You should not be responsible for this $35 charge.The Plan denied your request. The Plan says this service is not covered under the 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. The health plan contract says that any services not listed under the Description of Benefits is not covered.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 forthe intraoral periapical first x-ray (D0220) provided January 5, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received December 29, 2020 from the out-of-network provider.You asked the Plan to pay forthe extraction. You say that you were advised that this provider was in-network.The Plan denied your request. The Plan says there is no coverage for services received out-of-network.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.The extraction was received outside of the Plan's dental network. Therefore, we decided that the Plan does not have to pay forthe extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received December 29, 2020 from the out-of-network provider.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapy services (97110) provided August 26, 2020.You asked the Plan to pay forthe therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services 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 CPT code 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home. There is a more appropriate CPT code for the services provided. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met.Therefore, we decided that the Plan does not have to pay fortherapy services (97110) provided August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided January 25, 2021.
You asked the Plan to pay for the dental exam, cleaning and bitewing x-rays. You say that you have been seeing this provider for years and felt uncomfortable going to a different provider since you do not know their disinfecting procedures during the pandemic. The Plan denied your request. The Plan says this provider is not contracted with the Plan and the Plan had other providers who could have rendered the same care therefore the services 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. The Plan covers the dental exam, cleaning and bitewing x-rays when the services are performed by a network provider. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. 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. Based on this information, we decided that the Plan's rules for coverage of the dental exam, cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services (D2950, D3330) received February 18, 2021 from the opt-out provider.You asked the Plan to pay forthe dental services (D2950, D3330). You say that you were given approval to see this provider.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. Services received from an opt-out provider will not be 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, the requested items or services are not among those covered under this benefit. The Plan has submitted evidence that this provider has opted out of Medicare. Therefore, we decided that the Plan does not have to pay forthe dental services (D2950, D3330) received February 18, 2021 from the opt-out provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on January 4, 2021.
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request. The Plan says the service was processed under your medical insurance, which resulted in a $25 copayment.
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 $25 copayment for Medicare covered vision services. You have been asked to pay $25 copayment for the ophthalmological services. The ophthalmological services falls within the Medicare covered vision 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 ophthalmological services provided on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at a lower, less intensive level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Fasenra rendered on November 16,
2020 and January 11, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the denial. The
Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there a 20% coinsurance for Medicare Part B prescription drugs.
Review of the file shows that you received Fasenra on November 16, 2020 and January 11, 2020. You have
been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on
the contract with the Plan. This cost sharing is a contractual obligation that you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the Fasenra
rendered on November 16, 2020 and January 11, 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. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that the patient is a 67-year-old male who was admitted to the current acute care hospital with osteomyelitis and associated chronic left foot wounds and left leg pain. The patient is more stable and improving and only requires short-term acute care hospital need which can safely be administered at the current facility. There are no services at the LTACH that the patient requires that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic CGM (K0554) with supplies (K0553).

You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a therapeutic CGM and supplies have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day nor use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM (K0554) with supplies (K0553).
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital with gangrene. You are now medically stable with 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.
You may benefit from further therapy but do not require an intensive therapy program in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remodulin.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Remodulin.
Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a corneal pachymetry provided on February 15, 2021.

You asked the Plan to waive the copayment for the corneal pachymetry. The Plan denied your request. The Plan says the cost of the test is lower than the Plan's copayment. The cost sharing of $11.40 was assessed on the claim.

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 $35 copayment for outpatient diagnostic tests and therapeutic services.

You have been asked to pay $11.40, which is less than the $35 copayment for the corneal pachymetry. The corneal pachymetry falls within the outpatient diagnostic tests and therapeutic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a corneal pachymetry provided on February 15, 2021.