Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for the power options.
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 based on the medical records provided there is no documentation that the enrollee meets Medicare criteria for the various accessories. The records do not document a need for bladder catherization, presence of muscle spasticity or high risk for skin breakdown, thus the power tilt is not covered. The seat elevator is statutorily non-covered by Medicare. As the enrollee does not meet criteria for the requested accessories, a group 3 power wheelchair with no power option is appropriate but not a group 3 power wheelchair with a single power option. 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 for the enrollee.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 the enrollee appears to still require short-term additional acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Completion of care at the current location is recommended prior to transfer to a lower level of care when appropriate.

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a test of nerves and muscles (95908) provided on July 1, 2021.  

You asked the Plan to waive the copayment the test of nerves and muscles. You say that the services should be covered as you feel the services were inadequate. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for Outpatient diagnostic tests and therapeutic services and supplies.     

You have been asked to pay a $95 copayment for the test of nerves and muscles. Tests of nerves and muscles fall 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 a test of nerves and muscles (95908) provided on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the care can be safely received in another setting, such as a skilled nursing 
facility or home with home health care services.

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 there is no documentation provided indicating medical necessity for 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 he/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 services 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic procedure, neuromuscular re-education (97112) vasopneumatic device (97016) unlisted therapeutic procedure (97139) therapeutic, prophylactic, or diagnostic injection (96372) unclassified drugs (J3490x5) compounded drug, not otherwise classified (J7999x3) thiamine hcl injection, 100 mg (J3411) pyridoxine HCl injection, 100 mg (J3415) provided August 23, 2021.  

You asked the Plan to pay for the outpatient services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered benefits under Medicare.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    

We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy in the State of Oklahoma.  

The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, neuromuscular re-education (97112) vasopneumatic device (97016) unlisted therapeutic procedure (97139) therapeutic, prophylactic, or diagnostic injection (96372) unclassified drugs (J3490x5) compounded drug, not otherwise classified (J7999x3) thiamine hcl injection, 100 mg (J3411) pyridoxine HCl injection, 100 mg (J3415) provided August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #8 and #9.
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says the x-rays do not show that the teeth have decay or loss due to fracture involving more than 50% of the biting edge of the tooth.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the provided radiographs show teeth #8 and #9 each with a large mesial restoration which likely involve the mesial and lingual surfaces. The incisal edges do not appear to be involved, or at most very minimally, and it does not appear that more than two surfaces are involved on either tooth. Crowns are usually considered where a substantial amount of structure is missing, most often about 50% or more.
The need for the strength of a crown has not been shown to be needed in this instance as there is still about 65% of the structure still intact. The plan's criteria for anterior crowns has not been met. The plan provides that for anterior teeth 50% of the incisal edge must be involved along with at least four surfaces. In this instance, there are only two surfaces seen to be involved and only possibly a tiny fraction of the incisal edge near the mesial contact area. Due to the limited structural damage seen, the plan criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #8 and #9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography, bilateral (two-view study of each breast) (77067) and screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77063) provided August 27, 2021.
You asked the Plan to pay for the diagnostic service. You say that this is coded correctly and screening mammograms are paid once a year. Therefore 77067 and 77063 are payable codes and need to be reprocessed correctly. The Plan denied your request. The Plan says payment may be made for only one screening mammography performed on a woman over age 34 but under age 40.
The Plan must follow Medicare rules. Medicare rules say that payment may be made for only one screening mammography performed on a woman over age 34 but under age 40.
We looked at the file and Medicare rules. The records show that the Plan had already approved payment of 77067 and 77063 the same provider, for date of service August 26, 2020. Therefore, the benefit is available at this time. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammography, bilateral (two-view study of each breast) (77067) and screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77063) provided August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on May 4, 2021, and May 7, 2021.

You asked the Plan to pay for the services provided. You say that the procedure relieved your sciatic pain. The Plan denied your request. The Plan says services other than manipulation are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The file shows that you received manual manipulation on May 4 and 7, 2021. You were charged a $5 copay per your plan contract. You also received an office visit was provided on May 4, 2021. Services other than manual manipulation, when provided by a chiropractor are not a covered service. We found no exception which would require the Plan to further pay for the services at issue. Therefore, we decided that the Plan does not have to further pay for the chiropractic services provided on May 4, 2021, and May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on August 3, 2021.

You asked the Plan to waive the copayment for the telehealth visit. You say that you do not think you should be charged a specialist copayment for a conversation with a provider that lasted about thirty (30) seconds on the phone. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you received telehealth services on August 3, 2021. You were asked to pay a $15 copayment for the telehealth visit. You pay the cost-sharing that applies to primary care services or specialist physician services for Medicare-covered telehealth services received from your PCP or a specialist. 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 telehealth visit provided on August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from August 25, 2020, through August 31, 2020.  

You asked the Plan to pay for inpatient hospital care. You say that you disagree with the denial stating that clinical information does not support assignment of the original DRG. The Plan denied your request. The Plan says the clinical documentation does not support that the following diagnosis impacted this hospital admission-- N17.0 Acute kidney failure with tubular necrosis.  

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 N17.0 defined as Acute kidney failure with tubular necrosis. 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 inpatient hospital care. Our physician reviewer found the review indicates that the enrollee was a then, 44 years old enrollee with a known history of stage IV chronic kidney disease and chronic meningitis presented to the emergency department (ED) with severe headache and neck pain. On arrival to the ED there is documentation the enrollee'screatinine was 2.97, with the ED provider documenting "moderate chronic renal insufficiency." There is no mention in the medical record of a clinical concern for "vasomotornephropathy" until the discharge summary. The discharge summary did not reference in the Hospital Course description of any clinical concern for acute tubular necrosis (ATN) and there was no documentation of directed treatment. The Nephrology service was not consulted. The review has determined that N17.0 Acute kidney failure with tubular necrosis diagnosis was not supported by the medical records.   

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 care provided to the enrollee from August 25, 2020, through August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on April 15, 2021.
You asked the Plan to pay for a shoulder elbow wrist hand orthosis. You say that this is supported in the records. The Plan denied your request. The Plan says required documentation has not been submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There is not an itemized delivery ticket or invoice to show that the specific item at issue was delivered. The record shows that
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August
16, 2021.
You asked the Plan to waive the copayment for the laboratory work. You say that you do not believe you
should be charged by this provider for this service. 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 $10
copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). For this
date of service, you have been asked to pay the allowed amount of the claim because this amount is less than
the standard $10 copayment for the laboratory work.
You have been asked to pay a $6.84 copayment for the laboratory work. The laboratory work 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 the laboratory work provided on August 16, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and bitewings - four radiographic images (D0274) provided October 18, 2021.

You asked the Plan to pay for the periodic oral exam and bitewing x-rays. You say that you cannot afford the cost of the services. The Plan denied your request. The Plan says you have exceeded your dental maximum and are responsible for the cost of the services.

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. The Plan covers periodic oral exams and bitewing x-rays up to the $2,750 allowance. 

We looked at the file and Medicare rules. The Plan provided documentation showing that the full $2,750 was applied towards your dental claims prior to the services at issue. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and bitewings - four radiographic images (D0274) provided October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the periodontal scaling and root planing (D4341) 
provided on September 1, 2021.

You asked the Plan to pay in full for the scaling and planing. You say that the hygienist told you that this 
service would be covered under your insurance, and never advised what your part would be. You also say that 
no one told you this service would not be covered at 100%. The Plan denied your request. The Plan says this 
claim is processing correctly with a $54 coinsurance charge as this is a comprehensive dental service.

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 a 50% 
coinsurance for this service. Therefore, we decided that the Plan does not have to pay in full for the periodontal 
scaling and root planing (D4341) provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Oxycodone HCL 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 requested drug is intended for patient self-administration.  

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 Oxycodone HCL for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (28289) provided June 24, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service was performed by a certified surgical technician. This type of provider is not eligible for payment.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (28289) provided June 24, 2021.