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

We decided that the Plan does not have to pay for inpatient care provided from May 14, 2020, to May 19, 2020,
and billed with DRG (diagnosis related group) 377.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your
request. The Plan says the billed DRG is not supported.
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 DRG 377, gastrointestinal hemorrhage with major
complications or comorbidities. 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 the billed DRG is not supported. Our physician reviewer found while the records
support an admission for a gastrointestinal bleed, they are inconsistent regarding a diagnosis of acute
respiratory failure. There is no clinical or laboratory evidence of respiratory failure with hypoxia.
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 care provided from May 14, 2020, to May 19, 2020, and billed with DRG (diagnosis related
group) 377.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the provider your currently see does not currently offer a comprehensive cardiac program. The Plan denied your request. The Plan says you are already enrolled in the cardiac program with a different provider and there is no medical indication for an out of plan referral at this time.
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 cardiac rehabilitation to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for implantable hormone pellets (11980) provided March 31, 2021 from an out-of-network provider.
You asked the Plan to pay for implantable hormone pellets. You say that you would like to appeal because you need the medication and feel that it should be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for implantable hormone pellets (11980) provided March 31, 2021 from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are at risk every day of falling. You state the
caretaker is not able to care for you twenty-four (24) hours a day and you very much need the help. The Plan
denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that
need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can
safely be received at a different setting, for example, home with home health, in residential care, or home with
close follow-up with your doctor.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF coverage.
The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled
therapy needs. The enrollee is consistently ambulating more than one hundred (100) feet and tending to
activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care
needs are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 18, 2021.
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 procedure code 25600 is not supported.
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 25600 is closed treatment of distal radial fracture (eg,
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when
performed; without manipulation.
We find that CPT code 25600 is not supported in the medical record. Specifically, there is no documentation of
closed treatment of distal radial fracture or epiphyseal separation. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the surgical services rendered on January 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you still do not have the strength to be able to go
home. You state the last time you went home too soon you could not even get in your house. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement (11043, 11042, 17250) provided on
September 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for wound debridement. You say that the service was rendered due to medical
necessity and patient care was provided as an urgent request from the PCP to avoid wound complications such
as: deterioration, amputation, infection and or hospitalization. The Plan denied your request. The Plan says
based on the member's medical records and the provider's assessment, the appellant's argument does not fall
under the Out-of-Network exception for emergency or urgent patient 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.
Authorization should be obtained from the plan prior to seeking 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 wound debridement (11043, 11042, 17250)
provided on September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on August 17, 2021.
You asked the Plan to pay for the resin-based composites. You say that you want to know why the fillings
aren't being paid. The Plan denied your request. The Plan says reimbursement has already been issued for two
fillings.
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
two fillings per calendar year. The Plan paid for two resin-based composites provided on July 13, 2021, which
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites
provided on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
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 inpatient mental health treatment. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review
of the records provided you do not meet the criteria for continued acute inpatient mental health treatment for
the dates in question of December 16, 2021 forward as you were not shown to be a danger to yourself or others.
You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.
You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography, head (70544) provided
January 21, 2020.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your
request. The Plan says the provider has not submitted any clinical records to support the medical necessity of
the 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, we have confirmed that code the
diagnostic service is a column II code to column I code 70551-26. 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 magnetic resonance angiography, head
(70544) provided January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qvar Redihaler.
You asked the Plan to pre-approve Qvar Redihaler. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 pre-approve Qvar Redihaler.
Benefits for Qvar Redihaler 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 12, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that ConfirmMDx is covered for males with previous
negative prostate biopsy who are being considered for repeat biopsy.
We looked at the file and Medicare rules. The records show that the enrollee was not being considered for a
repeat biopsy. Based on this information, we decided that Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered
on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a problem focused limited oral evaluation (D0140), and cone
beam CT therapy (D0364) provided by an out-of-network provider on September 17, 2021.
You asked the Plan to pay for a problem focused limited oral evaluation, and cone beam CT therapy. You say
that you believe that the Plan should pay for this. The Plan denied your request. The Plan says the dental
services that were provided 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.
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 when provided by an out-of-network provider. Therefore, we decided
that the Plan does not have to pay for a problem focused limited oral evaluation (D0140), and cone beam CT
therapy (D0364) provided by an out-of-network provider on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on April 22, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on
August 16, 2021.
You asked the Plan to pay for a crown. You say that you would like the Plan to pay for these services. The Plan
denied your request. The Plan says a crown is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown
(D2740) provided by a participating provider on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you received on July 27, 2021.
You asked the Plan to waive the copayment for the EKG. You say that this was part of your annual wellness visit, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($14.66) is less than your copayment obligation, you are responsible for the full allowed 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 non-radiological diagnostic services.
You have been asked to pay a $50 copayment for the EKG. Your Evidence of Coverage explicitly states that diagnostic testing is not included in your annual wellness visit and separate cost sharing applies. The EKG falls within the non-radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you received on July 27, 2021.
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 the stay is medically necessary. The Plan denied your request. The Plan says the medical records received do not support that you have completed your full course of care in the hospital or that once stabilized that you will require the special long term acute care available at an LTACH (specialized nursing care and daily doctor visit) or that you will require long-term acute care for more than 25 days. The Plan states LTACHs do not provide clinical advantage over a non LTACH acute care hospitals. The Plan states you may be able to safely receive the care you need in another setting such as a skilled nursing facility (SNF) level of care or home with home care once you no longer require services in the acute care hospital.
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 LTACH services. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 25, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. 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. The records provided for
review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 25, 2021, by an
out-of-network (OON) provider.