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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are currently unstable for transfer and do not appear able to participate in rehab therapies for 15 hours with a 7 consecutive day period.
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.
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical management of lumbar fracture after a fall, anemia, pneumonia and surgical management of a brachial artery pseudoaneurysm Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the service is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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 (E0676).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on January 28, 2021.
You asked the Plan to pay for the therapeutic exercises. You say that you attached the medical records required to reprocess the denied claim. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.
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 97110 has a bundled relationship with code 92526 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 the therapeutic exercises provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 16, 2021.
You asked the Plan to pay for the limited evaluation. You say that this service was necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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 limited oral evaluation (D0140) provided on March 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation
services (A0427, A0425) provided on May 21, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this
bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was
assessed in accordance with your contract.
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 ambulance services.
You have been asked to pay a $300 copayment for the ambulance services. 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 emergency ambulance transportation services (A0427, A0425) provided on
May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and fluoride varnish application provided on June 10, 2021.
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis and fluoride varnish application. You say that you have a $0 copayment for exams, cleanings, x-rays and fluoride in or out-of-network. You say that the Plan did not cover 100% of the cost of these preventive procedures. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network benefits.
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 Plan is only obligated to pay the allowed amount for the periodic oral evaluation, prophylaxis and fluoride varnish application when received from an out-of-network provider. You are responsible for any charges above what the Plan pays. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and fluoride varnish application provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 11, 2021, through January 14, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was revised in this case.
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. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the member presented with seizures and AMS. There is evidence of a history of a previous seizure disorder. Her toxicology screen was positive for cocaine and marijuana. She was given Narcan and her AMS resolved. The clinical documentation suggests drug related (cocaine) poisoning with a complication of a seizure (DRG 918). The review indicates that the plan revised this claim to DRG 918 from 100 and then 1010. This was the correct move on the plan's part. 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 hospital services provided to the enrollee from January 11, 2021, through January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk assessment testing provided on May 5, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was ordered to evaluate for disease risk and is not covered for screening purposes.
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 test at issue in this appeal, genetic testing, 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 hereditary cardiovascular risk assessment testing provided on May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that the enrollee has dementia. You also say that this drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Aduhelm. Our reviewer says that Aduhelm is not medically necessary. Our physician reviewer found the provided documentation does not contain a neurological examination, and it is not clear that the enrollee has a diagnosis of mild cognitive impairment or mild dementia stage of Alzheimer's disease. The provided magnetic resonance imaging (MRI) suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. The documentation does not support that the Aduhelm is medically reasonable and necessary for the enrollee in this case. The reviewer also found that the documentation is insufficient to support that the drug is expected to be safe and effective for this 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 Aduhelm have not been met. Specifically, the file does not contain clear evidence of mild cognitive impairment or mild dementia stage of Alzheimer's disease. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).

You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says results of EGFR and ALK are required to establish medical necessity for single agent pembrolizumab.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Keytruda. Our physician reviewer found that the enrollee has recurrent non-small cell lung cancer. The requested use of the drug is not approved or supported without epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) testing results. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you had on May 13, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you were told the copayment for this test was $15. You said that you would never have had the test done had you known it would cost an additional $100. 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 $115 copayment for radiological diagnostic services. You have been asked to pay a $115 copayment for the TTE. The TTE falls within the 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 transthoracic echocardiography (TTE) you had on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on January 7, 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 99152 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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological
status for the first 15 minutes. 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 moderate sedation services rendered on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond fixed partial denture (D6930)
provided on February 24, 2021.
You asked the Plan to pay for the re-cement or re-bond fixed partial denture (D6930). You say that the
alternative treatment was more expensive, and you chose the crown repair to save the Plan money. 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 recement
or re-bond fixed partial denture (D6930) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays
(D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and periodontal procedure
(D4999) provided on April 26, 2021, by a Medicare opt-out provider.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, topical
application of fluoride varnish, and periodontal procedure. You say that these services were obtained from a
staff dentist within the dental facility which is a single specialty business group that has not opted out of
Medicare. The Plan denied your request. The Plan says you received these services from a provider who chose
not to receive Medicare funds. The Plan also says that charges incurred by Medicare opt out providers will not
be reimbursed.

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
covered when they are rendered by a Medicare opt out provider. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), prophylaxis (D1110),
topical application of fluoride varnish (D1206), and periodontal procedure (D4999) provided on April 26,
2021, by a Medicare opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

we decided that the Plan does not have to pay for the supervision of a nursing facility enrollee services coded
99380 provided on March 27, 2021.
You asked the Plan to pay for the supervision of a nursing facility enrollee services. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
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, the CPT Code Manual definition of code 99380 is supervision of a nursing facility patient (patient
not present) requiring complex and multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of patient status, review of related
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care ecisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian)
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99380 is not supported in the medical record. Specifically, this code has a status code of
"B". A status code of B means that this code is always bundled into payment for other services not specified
and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage
of the supervision of a nursing facility enrollee services have not been met. Therefore, we decided that the Plan
does not have to pay for the supervision of a nursing facility enrollee services coded 99380 provided on March
27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you have been going to this dental facility for the last few years. You also say that you went on the internet to make sure the treating dental facility was still in-network prior to receiving the services. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did contact the Plan prior to the date of service to verify benefits and provider eligibility for another provider, not the provider you were treated by.
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 are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April
12, 2021 by an OON provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy rendered on June 4, 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 97010 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 97010 (hot or cold packs therapy) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy rendered on June 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427) and mileage (A0425), provided on March 26, 2021.
You asked the Plan to waive the copayment for the ambulance service and mileage. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $270 copayment for ambulance services. You have been asked to pay a $270 copayment for the ambulance service and mileage. This service falls within the ambulance 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 ambulance service (A0427) and mileage (A0425), provided on March 26, 2021.