Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4346, D9630, D4921, D0431).
You asked the Plan to pre-approve the services. You say that coverage should be reconsidered. The Plan denied your request. The Plan says the claim processed correctly in accordance with the contract.
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 pre-approve dental services (D4346, D9630, D4921, D0431).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81328, 81400, and 81223 provided on May 28, 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 CPT codes 81225, 81328, 81400, and 81223 are not supported in the medical record. Specifically, if a laboratory procedure produces multiple reportable test results, only a single code shall be reported for the procedure. Code 81479 would be more appropriate to be billed for the services rendered. Review of the file does not support that this service was billed with this code. 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 coded 81225, 81328, 81400, and 81223 provided on May 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (97750) provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for services rendered by an out-of-network provider unless urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (97750) provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on April 6, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the enrollee on April 6, 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 that 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. 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on June 6, 2021.
You asked the Plan to pay for the magnetic resonance angiography. 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. In this case, we have confirmed that code 70544 for the magnetic resonance angiography has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on June 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded as 71045 provided on April 25,
2021.

You asked the Plan to pay for the x-ray services. You say that you would like this claim reprocessed as the
place of service billed is appropriate. The Plan denied your request. The Plan says this claim has denied for an
inappropriate place of service 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 71045 is not supported in the medical record. Specifically, the claim was billed with an
outpatient place of service (22). The record shows the enrollee was an inpatient at the time services were
rendered. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not
been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded as 71045
provided on April 25, 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 you require acute rehabilitation and have been told you may never walk again if proper therapy is not obtained. The Plan denied your request. The Plan says under Medicare, your request 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental
gradient pressure pneumatic appliance (E0673), provided on March 29, 2021.
You asked the Plan to pay for the pneumatic compression device and segmental gradient pressure pneumatic
appliance. You say that the item was medically necessary. The Plan denied your request. The Plan says The
pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis
during and/or following surgery, at home, or in any setting. The enrollee used the equipment in the facility
during and/or after surgery. Payment for this service would have been included in the facility DRG or PPS
prospective payment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the pneumatic compression device and segmental gradient pressure pneumatic appliance
was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the pneumatic
compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on March
29, 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 you are unable to support your own weight and will not have much assistance at home. The Plan denied your request. The Plan says under Medicare, your request 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hands-on therapy techniques (97140) provided May 26, 2021.
You asked the Plan to pay for the chiropractic services. You say that you were guaranteed that this claim would be paid. You are not responsible for payment. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for hands-on therapy techniques (97140) provided May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient care from June 4, 2021, forward.

You asked the Plan to pre-approve continued inpatient care from June 4, 2021, forward. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee exhausted the acute hospital benefit.

The Plan must follow Medicare rules. Medicare rules say that a patient having hospital insurance coverage is entitled, subject to the inpatient deductible and coinsurance requirements, to have payment made on his/her behalf for up to 90 days of covered inpatient hospital services in each benefit period. Also, the patient has a lifetime reserve of 60 additional days. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient care from June 4, 2021, forward have not been met. Specifically, the record shows that the enrollee exhausted their benefit of 90 inpatient hospital days in a benefit period, as well as their 60 lifetime reserve days. Therefore, we decided that the Plan does not have to pre-approve continued inpatient care from June 4, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on
December 16, 2019. You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contracted
providers at the preferred provider rate if services are not available from preferred providers. You say that the
in-network benefits should be honored, and the claim processed for payment. The Plan denied your request.
The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services
incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, PT services cannot be paid incident to this provider's professional services. Therefore, we
decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on
December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December
30, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to receive a cleaning
and you have the dental benefit. You say that this should be covered, and the copayment should be waived. The
Plan denied your request. The Plan says a comprehensive oral exam is only covered once every 36 months.
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, you also have a maximum benefit of
one comprehensive oral evaluation every 36 months. The Plan paid for the comprehensive oral evaluation
provided on July 2, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to
pay for the comprehensive oral evaluation provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport
(A0998) provided on February 22, 2021.
You asked the Plan to pay for the ambulance response and treatment. You say that the ambulance providers
told you that it was not medically necessary for you to be brought to the hospital by ambulance. You feel you
should not be punished for following their recommendation. You had your spouse drive you to the hospital and
were then admitted, because you were told your ambulance transport would not be covered as it was not
medically necessary. The Plan denied your request. The Plan says the ambulance benefit is a transportation
benefit. If there is no transportation provided, there is no payable service.
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 February 22, 2021. 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 response and treatment without
transport (A0998) provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.

You asked the Plan to pre-approve a lightweight wheelchair. You say that the longer you are propelling in the standard wheelchair the more damage you are causing to your hands and shoulders. The Plan denied your request. The Plan says that your request is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance services (A0427) provided on January 8, 2021.
You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration because you should be paid separately. The Plan denied your request. The Plan says ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission, and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance services have not been met. Specifically, the record indicates that the member was inpatient on the billed date of service. The record also indicates that this transportation was to another hospital or freestanding facility to receive specialized diagnostic or therapeutic services. Payment for this service is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the emergency ambulance services (A0427) provided on January 8, 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 you are unable to walk and your husband can't take care of you. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a lumbar compression fracture after multiple falls. Your 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.