Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and direct placement of a restorative material to protect tooth and/or tissue form (D2940) provided on May 6, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and direct placement of a restorative material. You say that you were told by a Plan representative that this treating provider was in-network. The Plan denied your request. The Plan says these services are not covered.

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 problem focused limited oral evaluation (D0140) and direct placement of a restorative material to protect tooth and/or tissue form (D2940) provided on May 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 2, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the tests and monitoring should have been covered in full. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 2, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the prothrombin time testing and intravenous (IV) hydration provided during an emergency department (ED) visit on March 6, 2021.
You asked the Plan to pay for the lab testing and IV hydration. You say that the medical records support that this was medically necessary treatment. The Plan denied your request. The Plan says these services were billed with modifier -GZ. This means that payment was correctly denied.
The Plan must follow Medicare rules. Medicare rules say that claim lines with modifier -GZ must be denied without complex medical review. Although it appears these services may be reasonable and necessary, they cannot be paid due to the presence of modifier -GZ. A corrected claim may be appropriate, but payment cannot be made as billed. Therefore, we decided that the Plan does not have to pay for the prothrombin time testing and intravenous (IV) hydration provided during an emergency department (ED) visit on March 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on January 20, 2021.

You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says screening services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic screening provided on March 1, 2021.
You asked the Plan to pay for the testing services. You say that medical records support the services. The Plan denied your request. The Plan says experimental or investigational services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. In this case, there are insufficient records to show the results of the testing would be used to determine a specific treatment strategy or diagnosis. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic screening provided on March 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on May 3, 2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that this office visit was unnecessary. 
The Plan denied your request. The Plan says you have been asked to pay 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 $35
copayment for in-network Medicare-covered podiatry visit.

You have been asked to pay a $35 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry
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 podiatry visit provided
on May 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee is a severe fall risk which could lead to readmission to the hospital.
You state the enrollee has had increased weakness and requires additional help for transferring.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee is
medically stable with no daily skilled nursing needs. There are no documented daily skilled nursing needs, and
at the current level of function with low endurance, easy fatiguability, she cannot not tolerate or require daily
skilled therapies in an inpatient setting. Rehabilitation needs can be met in a long-term care facility with
therapies available on an infrequent basis as needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas machine and injection of a nutria-pharmaceutical blend of vitamins and minerals.

You asked the Plan to pay for Sanexas machine and injection of a nutria-pharmaceutical blend of vitamins and minerals. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were 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 Sanexas machine and injection of a nutria-pharmaceutical blend of vitamins and minerals. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of chronic pain syndrome, with chronic pain in the extremities for a period of at least three months prior to starting treatment. The documentation does not support that the enrollee had a diagnosis/condition that meets criteria for the services rendered. There is insufficient evidence to demonstrate that Sanexas and vitamin supplement injections are effective, medically reasonable and necessary for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas machine and injection of a nutria-pharmaceutical blend of vitamins and minerals have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas machine and injection of a nutria-pharmaceutical blend of vitamins and minerals.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the removal of torus mandibularis provided on April 15, 2021.
You asked the Plan to pay more for the removal of torus mandibularis. You say that you were informed you had to pay half of the upcoming surgery. You say that you can pay for the denture but not the surgery. The Plan denied your request. The Plan says the claim reprocessed to partially pay up to your annual $1,000 maximum.
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
$1,000 annually for covered dental services. The Plan made partial payment of $428 for the surgery, which met
the $1,000 maximum. The remaining amount is your responsibility. Therefore, we decided that the Plan does
not have to pay more for the removal of torus mandibularis provided on April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, foot (73630)
provided April 26, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you would like the
doctor's practice to reimburse you for the unnecessary charged that you've had to pay out of pocket. The Plan
denied your request. The Plan says the claim was processed with the correct copayment applied per the
Evidence of Coverage.
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 $35
copay in a specialist's office.
You have been asked to pay $33.38 for the diagnostic services. Since the allowed amount was less than copay
amount, you are responsible for the lesser amount. The diagnostic service 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 copayment
for radiologic examination, foot (73630) provided April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of sacral nerve stimulator coded as 64590, 95972and 64590.

You asked the Plan to pre-approve implantation of sacral nerve stimulator. You say that the medical records provided support the necessity of the services. The Plan denied your request. The Plan says the enrollee does not meet the criteria as in order to be approved a successful trial has to be performed first and it has not.

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 implantation of sacral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that a 2-week complex in-hospital trial of a sacral nerve stimulator is medically reasonable and necessary for the enrollee. In this case, as there was no improvement with the percutaneous sacral nerve stimulation test performed as an outpatient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of sacral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of sacral nerve stimulator coded as 64590, 95972and 64590.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for Home Health Aide services provided on October 1, 2020, through November 30, 2020 and January 1, 2021, through January 31, 2021.
You asked the Plan to pay for the Home Health Aide services. You say that you would like reconsideration because you have a valid referral from your doctor for these services. The Plan denied your request. The Plan says that these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to forward any evidence to support that the services rendered were not medically necessary. The documentation submitted does not include any clinical information. Additionally, there is a request from the member's provider for the billed dates of service. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for Home Health Aide services provided on October 1, 2020, through November 30, 2020 and January 1, 2021, through January 31, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a home ventilator. Our reviewer says that the requested equipment is not considered medically necessary and reasonable. Our physician reviewer found that this patient has morbid obesity, obstructive sleep apnea, and obesity hypoventilation syndrome. A diagnosis of COPD is listed, but this is not supported by pulmonary function tests and the patient is on no medications for COPD. The patient is currently on Bilevel Positive Airway Pressure (BiPAP).

A recent arterial blood gases test while awake and stable documented carbon dioxide retention with a pressure of carbon dioxide of 56. The patient may benefit from changing to the average volume-assured pressure support mode of support, but this can be provided with certain BiPAP devices. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required
to establish a maintenance program or to prevent deterioration of your condition. At this point, your 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
You asked the Plan to pre-approve 5 additional physical therapy visits. You say that you can barely walk or balance which makes your activities of daily living difficult. You say that you need to be worked with to build up your strength. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 5 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our reviewer says that the Plan approved an additional 4 visits, which is adequate to finalize the home exercise program. Our physician reviewer found that the additional 5 visits will not accomplish weight reduction and her endurance can be improved with the home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection procedure you had at an outpatient hospital facility on April 12, 2021.
You asked the Plan to waive the copayment for the facet joint injection procedure. You say that this procedure was done in an office setting within the hospital and you believe the copayment is high relative to the services that were done. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan confirmed with the provider that the location where this service was performed is considered an outpatient hospital facility.
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 $300 copayment for outpatient services not provided in an ambulatory surgical center.
You have been asked to pay a $300 copayment for the facet joint injection procedure. The facet joint injection procedure falls within the outpatient services not provided in an ambulatory surgical center 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 facet joint injection procedure you had at an outpatient hospital facility on April 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.

You asked the Plan to pre-approve additional PT visits. 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 Medicare pays for medically necessary outpatient therapy. 

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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records you appear to have improved with therapy to the point of being able to walk two miles but is still having difficulty with descending stairs and with knee extension. Further skilled therapy beyond the now 23 approved physical therapy visits at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.