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

We decided that the Plan does not have to pay for the computed tomography (CT) head or brain (70450) provided April 22, 2021.
You asked the Plan to pay for the CT scan. 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 this code is not separately payable according to incidental/mutually exclusive CMS NCII edits.
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 70450 is computed tomography, head or brain. We find that CPT code 70450 is not supported in the medical record. Specifically, the provider has not submitted any clinical records to support the medical necessity of the service. The Plan made multiple attempts to obtain the needed records without success. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) head or brain (70450) provided April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from February 4, 2021, to February 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment 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 per day for days 1-6 for inpatient hospital services. Records show that you were in the hospital for 4 days. You were charged a $295 copayment per day for a total of $1,180. 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 inpatient hospital services you received from February 4, 2021, to February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an aqueous drainage device for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says in order for this to be covered, there would need to be documentation of the use of ocular hypotensive medication.
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 procedure. Our reviewer says that the requested procedure is medically reasonable and necessary. Our physician reviewer found the enrollee is not receiving ocular hypotensive medication. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an aqueous drainage device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Briviact tablet, 25 mg.
You asked the Plan to pre-approve Briviact. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is 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 pre-approve Briviact tablet, 25 mg.
Benefits for Briviact 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, E2377, E1028, E2620, E0956, E2311, E0705, E2313, E2607, K0108, E0955, E2359, K0040, E1007).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found it is not clear if the mobility deficit significantly impairs MRADLs in the home. The documentation is inconsistent on your neurological exam. The 8/17/21 document notes neurological-intact on the physical exam. Your upper extremity strength and independence in feeding, bathing, dressing, toileting and meal prep are noted and it is not clear given your strength and function why you would be unable to operate a manual wheelchair. You do not have increased tone, intermittent catheterization, or inability to perform a functional weight shift therefore the power tilt and recline are not medically necessary. The E2311, E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary as the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee 's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. 

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 pre-approve a group 3 power wheelchair and accessories (K0861, E2377, E1028, E2620, E0956, E2311, E0705, E2313, E2607, K0108, E0955, E2359, K0040, E1007).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on March 18, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you received telehealth services and were not seen in person and should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for specialist services, including telehealth services. You have been asked to pay a $40 copayment for specialist services. Specialist 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 specialist services provided on March 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the member received surgery and needed to go to a rehabilitation facility but went to a skilled nursing facility (SNF) and received a urinary tract infection. You say that the physician wants him to have inpatient rehabilitation because the SNF does not have the appropriate rehabilitation that member needs. The Plan denied your request. The Plan says the documentation does not appear to support requirement of physician supervision by a rehabilitation physician making face to face visits at least 3 times per week. It appears the medically necessary rehabilitation needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care.
Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted from a skilled nursing facility for syncope and urinary tract infection. He was receiving care in the skilled nursing facility after resection of a benign brain tumor. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on June 17, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you made an appointment for a cleaning. You also say that you were not advised about the extra dental benefit provided to you that was applied with your teeth cleaning. The Plan denied your request. The Plan says this service 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. The only type of x-rays that are covered under your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from November 6, 2020, to November 30, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the how the claims were processed and thought that this was taken care of. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 20% coinsurance for DME and related supplies. You received DME and related supplies from November 6, 2020, to November 30, 2020. The total allowed amount is $2,125 and 20% of that is $425.
You have been asked to pay the total coinsurance amount of $425 for DME and related supplies. DME and related supplies fall within the DME and related 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 DME and related supplies provided from November 6, 2020, to November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0801) and a battery (E2365).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show that the home has adequate access for this wheelchair.
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 services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly indicate a mobility deficit that impairs MRADLs in the home. It is not clear that the mobility deficit would not be able to be ameliorated by a walker, cane, or manual wheelchair. The documentation does not reveal that the enrollee can safely maneuver the wheelchair 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0801) and a battery (E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the urinalysis provided on February 25,
2021, by an OON provider.

You asked the Plan to pay for the office visit and the urinalysis. You say that the services were 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the office visit and the urinalysis provided on February 25, 2021,
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 27, 2021.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is not separately payable.
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 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from April 9, 2021, to April 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't
remember going to the hospital at all on this date. The Plan denied your request. The Plan says you were
charged this copayment 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 $325
copayment per day for days 1-5 for inpatient hospital care.
Records show that you went to the emergency room on April 9, 2021, and were evaluated for abnormal labs,
altered mental status, and cough. The records show that during this encounter, you reported intermittent
episodes of weakness and fatigue for the previous month, and you had worsening confusion in the five days
prior. After your emergency room evaluation, you were admitted to the hospital later that day and discharged
the following day. You have been asked to pay a $325 copayment for your one-day inpatient admission. 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 inpatient hospital services you received from April 9, 2021,
to April 10, 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 you would like the Plan to cover the LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services you are requesting do 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 necessitating 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 service 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D photographic images (D0350 x 2), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on March 25, 2021.
You asked the Plan to pay for the dental services. You say that you did not ask for these x-rays. You say that you only asked for bitewing x-rays. You say that you did not know what exactly was being done. You also say that you would like the claim to be paid in full. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that 2D photographic images are not listed as covered services. The Plan also says that unspecified preventive service is not listed as a covered service either.
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 periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on the date of service in this case. Additionally, the 2D photographic images and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D photographic images (D0350 x 2), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on April 26, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that you asked for a company that pays for dental
expenses not for you to pay them. You say that you can't afford an insurance that does not cover simple
expenses. The Plan denied your request. The Plan says the service 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 the
intraoral x-ray provided on April 26, 2021.
Your complaint about making things worse 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