Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from April 26, 2021, through April 29, 2021.  You asked the Plan to pay for physical therapy services. You say that the physical therapy services were medically necessary. The Plan denied your request. The Plan says based on the information received, this service was not provided by you for the patient. You are not entitled to reimbursement for claims for non-patients or for services you did not render. Services by a provider who is not in the network for the member's plan are not covered. The code(s) billed may be eligible for coverage through the state's early intervention program.  The contract with the Plan says that the Plan covers outpatient rehabilitation services. Covered services include physical therapy, occupational therapy, and speech language therapy. Prior authorization may be required and is the responsibility of the enrollee's provider.  We looked at the file and the Plan's rules. The file shows that you did provide physical therapy services to the enrollee; however, the Plan did not pre-approve the physical therapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from April 26, 2021, through April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 2, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you had a stroke on the same date of service and don't have to pay it. The Plan denied your request. The Plan says the copayment 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 $225 copayment per day for Medicare-covered ambulance round-trip services.   You have been asked to pay a $225 copayment for the emergency ambulance services. The emergency ambulance services fall 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, basic life support, emergency transport (A0429) provided August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) and drugs or medicaments dispensed in the office for home use (D9630) provided on February 10, 2021.
You asked the Plan to pay for the gingival irrigations and drugs or medicaments. You say that the dental office advised that you needed preventive care because it would not make sense in getting your cavities filled when the disease would make your teeth fall out. 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 four gingival irrigations (D4921 x4) and drugs or medicaments dispensed in the office for home use (D9630) provided on February 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 for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to an LTACH.  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. The patient appears to be more stable and improving and should only require short-term additional acute care services that can be safely administered at the current facility until transfer to a lower level of care is appropriate. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic intra-articular facet injections.  You asked the Plan to pre-approve therapeutic intra-articular facet injections. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for the requested therapeutic injection services.  The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures will only be covered when the criteria listed in the Medicare rules section have been met.  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 therapeutic intra-articular facet injections. Our reviewer says that the requested services are not medically necessary based on Medicare criteria for coverage. Our physician reviewer found in this case, there is no documentation in the medical record as to why the enrollee is not a candidate for radiofrequency ablation. Therapeutic intra-articular facet injections are not considered medically reasonable and necessary unless there is documentation explaining why radiofrequency ablation procedure cannot be performed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic intra-articular facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic intra-articular facet injections.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hydroxyz Pam.  You asked the Plan to pre-approve Hydroxyz Pam. You say that the medication is necessary. The Plan denied your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxyz Pam.   Benefits for Hydroxyz Pam 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for partial hospitalization services provided to the enrollee on January 25, 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 partial hospitalization claims must include a mental health diagnosis as the primary diagnosis.  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 the denied partial hospitalization services are not supported in the medical records, as the diagnosis code of C92.50 (acute myelomonocytic leukemia, not having achieved remission) is not related to mental health. 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 pay for partial hospitalization services provided to the enrollee on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics.  You asked the Plan to pay for foot orthotics. You say that the item should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess capsules.
You asked the Plan to pre-approve Linzess capsules. You say that the records provided support the need or the drug in dispute. The Plan denied your request. The Plan says the enrolled does not have Part D coverage under their contract.
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 Linzess capsules.
Benefits for Linzess capsules may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on May 4, 2021.
You asked the Plan to pay for the services provided. You say that the testing should be paid in full. The Plan denied your request. The Plan says the claim 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). We looked at the file and the rules. The records show that you were reimbursed for the services at issue based on the Medicare allowed amount. The services fall within the Covid-19 testing and treatment benefit category. We found no exception which would require the Plan to further pay for the services provided. Therefore, we decided that the Plan does not have to further pay for the coronavirus testing provided on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on July 14, 2020, through July 21, 2020.  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 payment of DRG 191 is not supported, as a review of the records supports DRG 292.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 291 (HEART FAILURE AND SHOCK WITH MCC). 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 documentation supported an admission for hypertensive heart disease with heart failure. The documentation was inconsistent/unclear regarding a diagnosis of acute respiratory failure. Even though acute respiratory failure is documented throughout the records, supporting medical record documentation was not found. The review has determined that payment of DRG 191 was not supported, as a review of the records supports DRG 292.   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 on July 14, 2020, through July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on April 13, 2021, to April 15, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think you should have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $275 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.   You have been asked to pay a $275 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay $550 ($275 x 2 days = $550). The correct copayment has been to the inpatient care that were provided. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on April 13, 2021, to April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the enrollee on February 5, 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 records do not support the services 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.  In this case, the CPT Code Manual definition of code 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)."  We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 pay for anesthesia services (procedure code 99100) provided to the enrollee on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck (76536) provided on August 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not expecting this expense and you believed this service was part of the office visit. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ultrasounds require a $100 copayment.
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 $100 copayment for diagnostic radiology services.
You have been asked to pay a $100 copayment for the ultrasound. An ultrasound falls within the diagnostic radiology 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 ultrasound of the head and neck (76536) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 10, 2021.
You asked the Plan to pay for the dental service. You say that you were contacted to schedule your semi-annual dental appointment. You also say that you believe the services would have been covered had you waited another 8 days. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 plan years. 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 comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 18, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rocklatan Drops.
You asked the Plan to pre-approve the Rocklatan Drops. You say that you would like reconsideration because
the requested drug is medically necessary. The Plan denied your request. The Plan says Medicare Part B does
not covered self administered drugs
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 the Rocklatan Drops.
Benefits for the Rocklatan Drops 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 portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by a BiPAP is not covered.
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 portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. The provider has requested a home mechanical ventilatory (E0466) utilizing a pressure-cycled setting not a volume-cycled setting. In other words, the ventilator provides a varied pressure to meet a targeted volume with each breath rather than an actual set volume. These settings could alternatively be provided by a BiPAP device (E0471) with average volume
assured pressure support (AVAPS). Tthe patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve iron infusion (Venofer) for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show why this request was made, or why iron pills can't be used.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found intravenous iron with Venofer is indicated for the treatment of iron deficiency anemia. This enrollee has a normal hemoglobin and iron indices. The use of IV iron is not reasonable or medically necessary.   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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve iron infusion (Venofer) for the enrollee.