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

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 20, 2021.  You asked the Plan to pay for the initial hospital care. The Plan denied your request. The Plan says with the documentation provided it cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. The record shows that the Plan made multiple attempts to get medical records from the provider, but no records were provided. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder.  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 the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right shoulder pain. X-rays were performed and she was recommended home exercises, as well as physical therapy and an injection. The records do not support that she has fully exhausted the first line therapies for at least six weeks. There are no red flags from examination or other indications for the MRI at this time. The services are not reasonable or medically necessary.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.  You asked the Plan to pre-approve the wheelchair. You say that this is required to aide in weight shifts and pressure relief. The Plan denied your request. The Plan says there is no face to face evaluation with a provider.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no detailed neuromuscular examination from a treating physician supporting that you will be unable to to operate a manual wheelchair post amputation. There is no post amputation medical examination from a treating medical physician indicating a need for a power wheelchair or supporting that you can safely use the requested power wheelchair or that it will significantly improve MRADL participation. Without a detailed physician evaluation and without an evaluation of your medical and functional status post surgery the requested Group 2 power wheelchair and accessories cannot be deemed medically necessary at this time.  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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested visits are not part of a maintenance program to maintain the enrollee's condition or to prevent deterioration.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  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 pre-approve physical therapy services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oxygen concentrator (E1390), mask (E1399), gradient compression stocking (A6530), tubing (A4616), cannula nasal (A4615), hose connectors (A9999), and sales tax (S9999), provided on April 24, 2021 and April 29, 2021.  You asked the Plan to pay for the oxygen concentrator and supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says oxygen equipment is only covered when rented.  The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390), mask (E1399), gradient compression stocking (A6530), tubing (A4616), cannula nasal (A4615), hose connectors (A9999), and sales tax (S9999), provided on April 24, 2021 and April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interrogation device evaluations (93294, 93296) rendered by the out-of-network (OON) provider on June 30, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 interrogation device evaluations (93294, 93296) rendered by the out-of-network (OON) provider on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on September 7, 2021.  You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you were given misinformation and only went because you were told that you could, and the Plan had received their funds back. The Plan denied your request. The Plan says the frequency limits for these procedures have been exceeded.  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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on May 11, 2021 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on September 7, 2021.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pay for the home health care services provided from April 24, 2020, to May 22, 2020.  You asked the Plan to pay for the home health services. You say that the services were authorized prior to them being rendered to the enrollee. You also say that these services should be covered. The Plan denied your request. The Plan says that the claim for the dates of service in this case was received after the 12-month deadline. The Plan also says that the services are cot payable.  The Plan follows Medicare rules. The rules say that for institutional claims that include span dates of service (i.e., a "From" and "Through" date span on the claim), the "Through" date on the claim is used for determining the date of service for claims filing timeliness.  The record shows that a claim for the home health services was filed on May 11, 2021. This means that the claim was filed within the filing limits as the provider would have had until the "Through" date, or May 22, 2021, to file the claim. Therefore, we decided that the Plan has to pay for the home health care services provided from April 24, 2020, to May 22, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) scan of the heart.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the plan has no contractual obligation to cover services that are not covered by Medicare.  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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the denial included a lack of cardiac symptoms including hypertension. However, you have essential hypertension. On medications, you are at 130/84. You have hyperlipidemia for which she tried Atorvastatin but developed myalgia requiring discontinuation. You also have a history of prior carcinoid tumor in the lung. While coronary calcium CT can be considered a screening test by Medicare, the fact that you have hyperlipidemia and especially hypertension would qualify you for this imaging.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan of the heart.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 18, 2021.  You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not supported by the documentation.  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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.  We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes to support the coding criteria for this code. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
June 10, 2021, through June 11, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say the inpatient care was medically necessary. The Plan denied your request. The Plan says an inpatient stay was not medically necessary.
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 that the enrollee presented to the emergency department with right arm pain and malfunction of AV fistula of right arm. Dialysis was refused at the center. The enrollee was directly admitted to the hospital after interventional radiology performed a fistulogram with balloon angioplasty. Dialysis and monitoring was planned. The enrollee's vitals remained stable prior to and after admission. No other acute conditions are noted in the documentation. The enrollee tolerated the procedure without complication. There was no indication the enrollee required hospital services that would likely cross 2 midnights and they were stable. Observation care would have been most appropriate. 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 from June 10, 2021, through
June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup provided on July 19, 2021.

You asked the Plan to pay for the core buildup. You say that the dentist failed to quote a price for the additional cost of buildup of the tooth. You say that you are on a fixed income and are now stuck with this bill. The Plan denied your request. The Plan says the service is not a covered 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.

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 core buildup provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve laser hair removal for the enrollee.
You asked the Plan to pre-approve the removal. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation showing a trial and failure of less invasive treatments.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 removal. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found because of the recurrent cellulitis, laser hair removal should be curative in this situation. 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 removal have been met. Therefore, we decided that the Plan has to pre-approve laser hair removal for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued home health care services.  You asked the Plan to pre-approve continued home health care services. You say that you are medically justified to receive additional in-home care to deter and/or redirect any further unforeseen health ailments that could lead to potential injury or hospitalization. The Plan denied your request. The Plan says the services are not necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 continued home health care services. Our physician reviewer found there is documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Records indicate you have been receiving home health physical therapy treatment and has made improvements in transfer ability and lower extremity endurance, but deficits remain, and you are unable to transfer from a wheelchair to a lift chair in a safe manner. Further home health physical therapy does appear indicated 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 continued home health care services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health care services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for urgent care services provided on June 18, 2021.

You asked the Plan to reduce the copayment for urgent care services. You say that your primary care provider was not available. You say you should be charged the $10 copay even though it was not with your primary care provider. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each office visit to providers other than your primary care provider for urgently needed services.

You have been asked to pay a $45 copayment for urgent care services. Urgent care services fall within the Urgently Needed 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 reduce the copayment for urgent care services provided on June 18, 2021.