Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81000, P9604, 36415, 82306, P9604, 85027, 80053, 85025, 87086, 81000) provided on June 23, 2021 to June 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OOn laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not authorized.
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 laboratory services (81000, P9604, 36415, 82306, P9604, 85027, 80053, 85025, 87086, 81000) provided on June 23, 2021 to June 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the requested level of care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of an inpatient level of care.
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 psychiatric hospital services.
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on September 14, 2021, with Schizoaffective Disorder Bipolar Type and Unspecified Intellectual Disability Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted. The enrollee did have some internal preoccupation and auditory hallucinations however they were improved. The enrollee did not have any visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. 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 herself or others but was compliant with her treatment. 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 psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 29, 2021.
You asked the Plan to pay for the dental service. You say that you had a bad tooth that needed to be fixed. You say that the first dentist you saw could not do anything. You say that you had to go to another dentist. You also say that you cannot afford to pay for all of these exams. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency limit 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 limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 29, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and comprehensive oral evaluation (D0150) provided on July 8, 2021.
You asked the Plan to pay for the intraoral complete series x-ray (D0210) and comprehensive oral evaluation (D0150). You say that the crown and existing decay were found through the exam and x-rays. You say that there was a need for immediate action and are waiting on future services. The Plan denied your request. The Plan says an intraoral complete series x-ray and comprehensive oral evaluation are only covered once every three plan years.
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 complete series x-ray and comprehensive oral evaluation every three years. The Plan paid for the complete series x-ray provided on August 12, 2019 and the comprehensive oral evaluation on November 15, 2019, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and comprehensive oral evaluation (D0150) provided on July 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided December 17, 2020.
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says upon discharge of revocation of hospice benefits, fee-for-service Medicare continues to cover the beneficiary through the end of the month.
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 December 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498 87541, 87581, 87640 87798 and U0004 provided on May 21, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 87486, 87496, 87498 87541, 87581, 87640 87798 and U0004 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Assisted Living Facility place of service 13.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498 87541, 87581, 87640 87798 and U0004 provided on May 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided January 29, 2021.
You asked the Plan to pay for the outpatient services. You say that you have been trying to get info from the hospital. you finally got a release of info from them. The Plan denied your request. The Plan says an itemized bill was requested and not received.
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 find that the services are not supported in the medical record. Specifically, an itemized bill was requested from both you and the provider without success. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided January 29, 2021.
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 December 9, 2020.
You asked the Plan to pay for the ambulance services. You say that the transportation was necessary. The Plan denied your request. The Plan says prior authorization was not obtained.
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 ambulance services. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on December 9, 2020. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on December 9, 2020. The reviewer also found that the documentation did not support that the ambulance transport on December 9, 2020, was medically reasonable and necessary for the enrollee. 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 ambulance services have not been met. Specifically, the file shows that the enrollee could have been transported by another form of transportation. 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 December 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services

You asked the Plan to pre-approve the requested services. You say that the enrollee has difficulty complying with medical instructions. The Plan denied your request. The Plan says prior visits provided education and monitoring without any issues.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 requested services. Our physician reviewer found that based on the documentation provided, the enrollee does not have documented skilled nursing needs. Therefore, the requested additional services are not shown to be medically necessary or reasonable. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on January 6, 2021.
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says they did not have enough information to make the decision.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laminectomy (63047 and 63048) provided on May 20, 2021.

You asked the Plan to pre-approve the laminectomy. You say that you would like reconsideration because this procedure was successful in treating the member's condition. The Plan denied your request. The Plan says this procedure was 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 pre-approve the laminectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the magnetic resonance imaging of the lumbar spine does not show any evidence of severe spinal canal stenosis. 

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 laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve the laminectomy (63047 and 63048) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided on May 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 established patient assisted living visit (99336) provided on May 4, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the breast ultrasound (76642) provided on March 17, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $100 per day for a Medicare-covered ultrasound. You have been asked to pay $97.48 for the Medicare-covered ultrasound provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment.
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 adjust the copayment for the breast ultrasound (76642) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Influenza virus vaccine services provided on November 26, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the Influenza virus vaccine services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 Influenza virus vaccine services provided on November 26, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the wheelchair and accessories, knee x-rays and physical therapy provided from March 18, 2021, through June 18, 2021.

You asked the Plan to waive the cost for the wheelchair and accessories, knee x-rays and physical therapy. You say that you were not asked to pay the day of surgery and you also should not have to pay for the extended physical therapy necessary to restore your knee. You say that you are asking for review of the case and help in the matter. The Plan denied your request. The Plan says the claims processed 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 20% coinsurance for each Medicare-covered item from an in-network provider, a $35 copayment for x-rays from an in-network provider and a $40 copayment for each Medicare-covered physical therapy service from an in-network provider. 

You have been asked to pay a total of $246.11 for the durable medical equipment, knee x-rays and physical therapy.

The wheelchair and accessories fall within the "Durable medical equipment (DME) and related supplies" benefit category. The knee x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The physical therapy falls within the "Outpatient rehabilitation 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 cost for the wheelchair and accessories, knee x-rays and physical therapy provided from March 18, 2021, through June 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the remaining visits are not reasonable or necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
The file shows that 7 physical therapy visits were requested. The Plan has agreed to pre-approve 2 visits. 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 additional services. Our physician
reviewer found that the enrollee does not have documented skilled therapy needs. The enrollee appears to be
functioning at a level commiserate with a lower level of care. As such, the requested services are not shown to
be medically necessary or reasonable.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the famotidine injection provided during chemotherapy treatment on March 23, 2021, billed with code S0028.

You asked the Plan to pay for the drug as billed. You say that you believe this should be paid because the drug was given and correctly billed. The Plan denied your request. The Plan says this is billed with an invalid code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Code S0028 has a status indicator of "I" in the Physician Fee Schedule. This means the code is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the drug as billed have not been met. Therefore, we decided that the Plan does not have to pay for the famotidine injection provided during chemotherapy treatment on March 23, 2021, billed with code S0028.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).