Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have acutely complex medical diagnosis and do not require supervision by a rehabilitation physician.  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 weakness and a urinary tract infection after a recent admission for kidney stone. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and amalgam (D2160) provided on May 26, 2021.  You asked the Plan to reimburse you for the dental services. You say that your dental claims have always been paid. You also say that had you known that this dentist had opted out, you would not have gone to him for the services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services received by a dentist that has opted out of Medicare.  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, dental services received from a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and amalgam (D2160) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the hearing aids provided on May 25, 2021.  You asked the Plan to pay more for the hearing aids. You say that the claim was processed and paid incorrectly. You say that the benefit is $600 per ear every 36 months and the claim should be reprocessed according to the benefit. The Plan denied your request. The Plan says the maximum allowance for this service was paid and you are responsible for the balance.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $600 toward the cost of hearing aids every 36 months.   We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the Plan paid $600 toward the cost of the hearing aids, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the hearing aids provided on May 25, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care, first hour (99291) critical care, each additional 30 minutes (99292) provided February 18, 2021.    You asked the Plan to pay for critical care services. You say that you had billed hospice for the date of service as was advised the enrollee was not enrolled at time of service. Please review all attached documentation and reprocess the claim for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on February 18, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) critical care, each additional 30 minutes (99292) provided February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 28, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that the services were medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that the enrollee had exceeded the frequency limit prior to this service on June 24, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided December 3, 2019.  You asked the Plan to pay for the hospital discharge services. You say that please reprocess the claim for payment based on these extensions in place for COVID-19. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided December 3, 2019.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an extremity study (93970) provided on December 29, 2020.  You asked the Plan to pay for an extremity study. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $1000 deductible for covered services.   You have been asked to pay $219.15 for an extremity study. The service at issue falls within the outpatient diagnostics 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 pay for an extremity study (93970) provided on December 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 21, 2021 to February 19, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the non-contracted provider submitted the RAP claim on March 25, 2021 for the home health care period which started on January 1, 2021.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that the RAP for this home health period was not submitted within 5 days from the start of care. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 21, 2021 to February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia for the enrollee.  You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication zoledronic acid, an IV bisphosphonate drug, would likely be less effective, and/or cause adverse effects for the member.  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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Prolia. There is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on July 24, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was not obtained.  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 pain management services provided on July 24, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on November 9, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on November 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on December 27, 2020.

You asked the Plan to pay for the ambulance service. You say that this was for emergency medical services (EMS) care with no transport. You also say that you would like help paying for this. The Plan denied your request. The Plan says there was no transport provided. The Plan says that the ambulance benefit is a transportation benefit and without transportation 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 December 27, 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 response and treatment, no transport, (A0998) provided on December 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for fillings (D2391, D2330), and does not have to pay for retainer crowns (D6752 x2), and pontic (D6242) provided on June 24, 2021.  You asked the Plan to pay an additional amount for fillings, and to pay for retainer crowns, and pontic. You say that some of the services at issue should be covered. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate for the fillings therefore no additional payment can be made. The Plan says retainer crowns and pontic are not covered services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of fillings, retainer crowns, and pontic have not been met. Specifically, the allowed amount of the fillings for an out-of-network provider were paid by the Plan. Additionally, retainer crowns and pontic are not covered services. Therefore, we decided that the Plan does not have to pay an additional amount for fillings (D2391, D2330), and does not have to pay for retainer crowns (D6752 x2), and pontic (D6242) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthoses (L1833), and sleeve (L2397), provided on April 8, 2021.  You asked the Plan to pay for the knee orthoses and sleeve. You say that the item is medically necessary. The Plan denied your request. The Plan says the medical records do not indicate medical necessity.  The Plan follows Medicare rules. Medicare rules say that codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.  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 knee orthoses and sleeve. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no medical records indicating knee instability.  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 knee orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833), and sleeve (L2397), provided on April 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc syringes.  You asked the Plan to pre-approve Synvisc. You say that your doctor is required to purchase this medicine from a specialty pharmacy, and Medicare should pay the cost of this medicine. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug will be supplied by a pharmacy and therefore is not covered by Medicare Part B benefits.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc syringes.   Benefits for Synvisc 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) on April 22, 2021.  You asked the Plan to pay for services provided between 10:00 PM and 8:00 AM. You say that this is supported int the records. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.    We looked at the file and Medicare rules. Code 99053 has a status indicator of B, meaning payment for this code is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insulin pump kit and cartridges to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the insulin pump it and cartridges. You say that you would like reconsideration because the requested pharmacy accepts your secondary insurance. The Plan denied your request. The Plan says there is an in-network pharmacy available to render the needed supplies.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.      The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the insulin pump kit and cartridges to be provided by an out-of-network (OON) 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 these services are medically necessary. The Plan denied your request. The Plan says that your 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. 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 dizziness and recurrent 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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.