Persius/hicric huggingface dataset:
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 a transfer is needed for your recovery. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and you do not require transfer to a 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 you are residing in an inpatient rehabilitation facility and have developed generalized weakness and were found to have an intraparenchymal hemorrhage in the right parietal, temporal, and occipital lobes. Follow up computed tomography (CT) scans confirmed additional subarachnoid hemorrhage. You have no significant swelling or midline shift with neurosurgery supporting a non-surgical approach with blood presusre management and anticonvulsant, seizure prophylaxis. Records show that you have a feeding tube for nutrition and no evidence of seizure activity. Your blood pressure has been low, prompting reduction in antihypertensive therapy. You have not been intubated and you have no evidence of complex wound, IV
medicated drips, or complex nursing care requirements. Patient receiving PT and OT with some progress. 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 and are 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a push-rim activated power assist device (E0986).  You asked the Plan to pre-approve the device. You say that you were not allowed to properly test the device. The Plan denied your request. The Plan says there is no evidence that you can safely operate the device.  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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that you would be able to safely use the requested device per the physical therapy evaluation on 8/23/21. The requested E0986 would not significantly improve your ability to perform MRADLs in the home.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a push-rim activated power assist device (E0986).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on August 13, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you received these drugs while in the emergency room. You say that you were not aware that you would be charged. You also say that you feel the drugs should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on August 13, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 71046) provided to the enrollee on August 1, 2021.
You asked the Plan to pay for the services. You say that there is a missing/incomplete/invalid/inappropriate place of service. The Plan denied your request. The Plan says this was billed with the appropriate place of service.
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 71046 is "Radiologic examination, chest; 2 views." We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records submitted (interpretation) did not indicate if the enrollee was inpatient or outpatient. The medical/billing records provided indicate the patient was inpatient on August 1, 2021, therefore Place of Service 22 would be inappropriate and 71046 would not be eligible for reimbursement consideration.
We looked at this coder'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 pay for imaging services (procedure code 71046) provided to the enrollee on August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 12,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic
decision-making in the clinical management of the patient and will be denied automatically as not medically
necessary.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review indicates that genetic testing procedures submitted with code 81455 are unlikely to impact
therapeutic decision-making in the clinical management of the enrollee and will be denied automatically as not
medically necessary. The review has determined that the enrollee does not meet the criteria for this request.
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 pay for laboratory services provided to the enrollee on April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pulmonary function testing performed on
July 9, 2021.
You asked the Plan to waive the coinsurance for the pulmonary function testing. You say that you previously
had this procedure in the office, but the doctor chose the hospital. The Plan denied your request. The Plan says
the correct coinsurance was applied.
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 20%
coinsurance for diagnostic procedures and tests.
Procedure
Allowed Amount
20% Coinsurance
Pulmonary Function
$1082.34
$216.47
Pulmonary Function
$345.24
$69.05
Pulmonary Function
$465.78
$93.16
Pulmonary Function
$462.00
$92.40
Spirometry
$10.04
$2.01
Plethysmography
$11.75
$2.35
CO2/membrane diffuse
$8.68
$1.74
Total:
$477.18
You have been asked to pay $477.18, which is 20% of the allowed amount for pulmonary function testing. Pulmonary function testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for pulmonary function testing performed on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the thromboendarterectomy (procedure code 35371) provided to the enrollee on January 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the requested service code is not substantiated by the clinical documentation in the operative report.
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 35371 is "Thromboendarterectomy, including patch graft, if performed; common femoral." We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report does not support CPT 35371 as a distinct procedure service from CPT 35302. The operative report describes that both CPT 35371 and CPT 35302 were performed in the right groin, and therefore would not be separately reported.
We looked at this coder'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 pay for the thromboendarterectomy (procedure code 35371) provided to the enrollee on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist physician services provided on August 26, 2021.
You asked the Plan to waive the copayment for the specialist physician services. You say that the doctor caused you additional pain. 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 $50 copayment for physician specialist services. You have been asked to pay a $50 copayment for the specialist physician services. The specialist physician services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist physician services provided on August 26, 2021.
Your complaint about the doctor's demeanor is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints. The Plan has confirmed they have addressed your complaint separately.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says 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 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 provided on August 12, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on February 14, 2021.
You asked the Plan to pay for the transportation services. You say that the transport took place when the billing office was closed. You also say that you were not aware that prior authorization needed to be obtained. The Plan denied your request. The Plan says the non-emergency ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation services. Our reviewer says that the transportation services was not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee could not have been safely transported by stretcher van or
other similar transportation. The reviewer found that the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the elements of the coverage criteria are not satisfied. 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 transportation services have not been met. Specifically, the file shows that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110)
provided on January 29, 2021.
You asked the Plan to pay an additional amount for the dental item. You say that your dentist advised that they
would do the dentures and accept payment quarterly. You say that you kept receiving bills for the denture. You
say that in August, the dental office advised that your insurance would not pay the remaining balance of the
bill. You also say that the remaining $500 should be covered. The Plan denied your request. The Plan says
there is an allowance of $375 per quarter for covered comprehensive dental services. The Plan also says that
the allowance for quarter 1 has 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 and dentures are eligible for coverage,
the quarterly allowance has been exceeded. The record shows that the Plan paid $375 towards the complete
upper denture that you received on the date of service in this case. Therefore, we decided that the Plan does not
have to pay an additional amount for the complete upper denture (D5110) provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-network provider on June 15, 2021.
You asked the Plan to waive the coinsurance for prophylaxis and a periodic oral evaluation. You say that you should be covered 60% for these services. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 50% coinsurance for prophylaxis/out-of-network and periodic oral exam/out-of-network.
You have been asked to pay a 50% coinsurance for prophylaxis and a periodic oral evaluation. Prophylaxis falls within the prophylaxis/out-of-network benefit category and a periodic oral evaluation falls within the periodic oral exam/out-of-network 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 coinsurance for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-network provider on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure.
You asked the Plan to pre-approve the intracept procedure. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered unproven as its clinical value and effectiveness has not been demonstrated in peer-reviewed literature.
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 the intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental and more research is needed to show its safety and efficacy. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 18, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the provider in January 2020 didn't perform a thorough cleaning so you switched dental providers. You say that you went for a cleaning but received a notice of denial of payment. 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 February 27, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 18, 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 would like reconsideration because the requested IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF services.
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 there are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member 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