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

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says outpatient treatment can be approved if there has not been discharge from the
hospital.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of
time, as she did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. The
enrollee did not show any abnormal behaviors, or any symptoms which would require acute treatment. It did
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or
others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric
services is 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says as acute care hospitals and LTACHs are licensed to provide the same level
of care, there is no advantage in moving from the current acute care hospital to an LTACH.
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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital.
The enrollee does not require services at the LTACH that are not available at the acute care hospital where she
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
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 admission to a LTACH for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81404) provided on September 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.

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 codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, and 81404, are column II codes to column I code 81445. This claim has not been billed with an appropriate modifier to bypass the edit. 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 services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81404) provided on September 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation (D3910), provided on May 27, 2021.
You asked the Plan to pay for the dental consultation. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 dental consultation (D3910), provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three resin-based composites (D2391), five surgical
removals of erupted teeth (D7210), and a mandibular partial denture (D5226).
You asked the Plan to pre-approve resin-based composites, surgical removals of erupted teeth and a mandibular
partial denture. You say that you have pain in your teeth, and it is hard to eat. The Plan denied your request.
The Plan says that you have exhausted your 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. The Plan covers two amalgam
or resin-based composite fillings and two non-surgical or surgical extractions per calendar year.
We looked at the file and Medicare rules. The file indicates the Plan has previously approved coverage for two
resin-based composites and two surgical extractions for this calendar year. Based on this information, we
decided that the Plan's rules for coverage of resin-based composites and surgical removals of erupted teeth have
not been met and that a mandibular partial denture is not covered by the Plan. Therefore, we decided that the
Plan does not have to pre-approve three resin-based composites (D2391), five surgical removals of erupted
teeth (D7210), and a mandibular partial denture (D5226).
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 you are stable enough to transfer to an LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to an LTACH does not meet the requirements for approval.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on May 18, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have 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 must 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 physician services provided to the
enrollee on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair ramp purchased on April 7, 2021.
You asked the Plan to pay for a wheelchair ramp. You say that your physician prescribed this ramp, and it
should be covered. The Plan denied your request. The Plan says ramps are not covered by Medicare.
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 rules state self-help equipment is not covered. A wheelchair ramp is
installed outside of the home and is used leaving and entering 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 pay for a wheelchair ramp purchased on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 19, 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 must 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 physician services provided to the enrollee on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The provided medical
records document that the enrollee has 3+/5 bilateral hand strength and is independent with feeding thus indicating the enrollee has adequate upper extremity strength and function to operate the power wheelchair's power options with their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to an inpatient stay provided from June 30, 2020, to July 3, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this deductible was not met at the time of services.
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 is $1000 deductible which applies to the 2021 Plan year. This cost sharing is a contractual obligation that had not been met at the time of service. Therefore, we decided that the Plan does not have to waive the cost share applied to an inpatient stay provided from June 30, 2020, to July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility telehealth visit (99308) provided on May 5,
2021.

You asked the Plan to pay for nursing facility telehealth visit. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says the benefit had been
exhausted from a previous telehealth service.

The Plan must follow Medicare rules. Medicare rules say that subsequent nursing facility care services are
limited to one telehealth visit every 30 days.

We looked at the file and Medicare rules. A covered subsequent nursing facility care telehealth service was
previously provided on April 21, 2021; therefore, 30 days had not passed before this service was provided.
Based on this information, we decided that Medicare rules for coverage of nursing facility telehealth visit have
not been met. Therefore, we decided that the Plan does not have to pay for nursing facility telehealth visit
(99308) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture (D5110) or pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 18, 2021.

You asked the Plan to pay more for the complete maxillary denture and to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you would like to appeal these services. The Plan denied your request. The Plan says your annual benefit maximum of $2,000 has been reached. The Plan also says that the comprehensive oral evaluation and panoramic x-ray exceed the frequency limitations in your benefit plan.

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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the June 18, 2021 date of service and your annual maximum benefit has been exhausted. The contract also says that comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on May 6, 2021 and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture (D5110) or pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from August 26, 2020, to August 27, 2020 with diagnosis related group (DRG) including diagnosis code I21.A1.

You asked the Plan to pay for inpatient care. You say that the diagnosis of I21.A1 is correct and subsequently the original DRG of 917 should remain unchanged. The Plan denied your request. The Plan says the denial of payment is correct, because the record does not support secondary diagnosis code I21.A1 so it was removed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with I21.A1, defined as myocardial infarction type 2. 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 inpatient care. Our reviewer says that this DRG does not meet the criteria for payment. Our physician reviewer found the documentation does not clearly support diagnosis I21.A1. Elevated troponins in the bloodstream indicate that there has been damage to the heart muscle and therefore can be an indicator of demand ischemia or a heart attack. However, if there is not mention of a myocardial infarction or documentation to support ischemia a query should be made to the provider before reporting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from August 26, 2020, to August 27, 2020 with diagnosis related group (DRG) including diagnosis code I21.A1.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve chest computed tomography (CT) angiography.
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 guidelines say that there must be doctor's notes that say why this test is needed.
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 you have known coronary
disease and hypertrophic obstructive cardiomyopathy (HOCM), and are status post coronary artery bypass graft
(CABG) from 2005. You have a strong family history of Ehler Danlos syndrome. You have dyspnea and
syncope, and you are being further evaluated for this. A CT scan done one year ago showed aortic disease and
moderate root dilatation. There is a letter (November 2021) from the treating cardiologist enclosed in the
records requesting the needed CT angiogram of the aorta to re-assess for aortic disease in the setting of this
medical history and the known prior aortic dilation.
This is a medically reasonable and necessary use of the CTA technology and meets the CMS criteria for its use
based on the specific enclosed request of the treating physician in this clinical 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 scan have been met. Therefore, we decided that the Plan has to pre-approve
chest computed tomography (CT) angiography.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on May 28, 2021.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you didn't know there was a facility charge and the services should be covered. The Plan denied your request. The Plan says the copayment 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 $295 copayment for Medicare- covered surgical services.
You have been asked to pay a $295 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the arthrocentesis provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 10, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not
a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
We looked at the file an the rules. The medical records provided do not show the testing at issue was ordered
due to signs and symptoms of the enrollee. The testing at issue in this appeal was requested for screening
purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the
Plan does not have to pay for the lab services provided on April 10, 2021.