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

We decided that the Plan does not have to pre-approve continuation of SNF care from October 16, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 the enrollee does not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The
documentation does not reveal evidence of complex daily wound care, new enteral feedings, or other skilled
nursing SNF need. The enrollee's wound vac is changed three times weekly. The enrollee's functional level
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily
basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis,
in a SNF setting beyond the last covered date.
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 continuation of SNF care from October 16, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided on April 6, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out-of-network physician services provided on
April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you received 
on February 15, 2021. 
 
You asked the Plan to waive the copayment for the EKG. You say that this EKG was needed prior to surgery, 
so it should be covered. The Plan denied your request. The Plan says the service was not denied, but you were 
assessed cost sharing.  The Plan says that you were charged this copayment correctly.  The Plan says that 
because the allowed amount for this service ($8.40) is less than your copayment obligation, you are responsible 
for the full allowed 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 $100 
copayment for diagnostic procedures and tests.  

You have been asked to pay a $100 copayment for the EKG. The EKG falls within the diagnostic procedures 
and tests 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 electrocardiogram 
(EKG) you received on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot you received on April 22, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that this boot does not fit and it is causing you pain. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan also says that your boot is under warranty until October 22, 2021, so you have the option of contacting the provider to report an issue.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the walking boot. The walking boot falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the walking boot you received on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee.

The Plan denied your request. The Plan says criteria for admission to an LTACH are not met. The enrollee is
receiving appropriate care in the current acute setting. An LTACH would not provide a clinical advantage and
is therefore not medically necessary.

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 in this case the enrollee was admitted with hypoxic respiratory failure due to
COVID-19 infection. The record indicates that the enrollee has had a complicated hospital course. The enrollee
continues to receive acute care services, and these have not been denied. The medical record does not indicate
that the enrollee requires services that they are not currently receiving but that would be available at the
LTACH facility. The elements of the coverage rules are not satisfied.

The requested transfer cannot be recommended.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Coflex Interspinous device in the setting of spinal surgery has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The coflex device is experimental. More research is needed to show safety and efficacy of the device. High failure rates have been reported with similar devices. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the paramedic intercept services you received on May 18, 2021.
You asked the Plan to waive the copayment for the paramedic intercept services. You say that you already paid a $300 copayment to the ambulance company that transported you. You say that you should not have to pay a second $300 for the fire department's services. The Plan denied your request. The Plan says that 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). In this case, two entities were involved in your care: an ambulance company that physically transported you, and a fire company that provided paramedic intercept services. The Plan has charged you a $300 copayment for each of these services. While we agree that paramedic intercept services are separately payable from the ambulance services, the Plan is still required to disclose any cost sharing obligations that would apply. Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for paramedic intercept services. Rather, your contract only lists a copayment for ambulance services, which is a $300 per one-way trip. You only had one one-way trip. Paramedic intercept services are not an ambulance 'trip,' so it is inappropriate for the Plan to assess ambulance cost sharing for paramedic intercept services. There is no other section of the Evidence of Coverage that lists an applicable copayment for paramedic intercept services. Because the contract does not clearly say how much enrollees must pay for paramedic intercept services, we find that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the paramedic intercept services you received on May 18, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 15, 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 29828 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 29828 is arthroscopy, shoulder, surgical; biceps
tenodesis.
We find that CPT code 29828 is not supported in the medical record. Specifically, there is no documentation of
a surgical shoulder arthroscopy with biceps tenodesis. 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 surgical services rendered on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 18, 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 separately payable.
The Plan must follow Medicare rules. The rules say that payment for follow-up visits are included in the global surgical package. We looked at the file and Medicare rules. Billed procedure code 99212 (office visit) was billed within 90 days of major surgical procedure 50590 (lithotripsy) performed on January 28, 2021. The office visit was related to the surgical procedure and payment is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home meal delivery (Meals on Wheels).
You asked the Plan to pre-approve Meals on Wheels. You say that you cannot prepare food for yourself and cannot afford food right now. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because home-delivered meals are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that home meal delivery (Meals on Wheels) is not covered by Medicare. We looked at the file and Medicare rules. This service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of Meals on Wheels have not been met. Therefore, we decided that the Plan does not have to pre-approve home meal delivery (Meals on Wheels).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110),
and preventive procedure (D1999) provided on June 21, 2021.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and preventive procedure. You say that
you expect this denial to be reversed and payments to be made to your dental provider. The Plan denied your
request. The Plan says you were not enrolled with a dental plan on this date of service that would obligate the
Plan to cover these services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation
(D0120), prophylaxis (D1110), and preventive procedure (D1999) provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of intra-aortic balloon assist device coded 33967 provided on June 1, 2021.

You asked the Plan to pay for the insertion of intra-aortic balloon assist device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 33967 is insertion of intra-aortic balloon assist device, percutaneous.

We find that CPT code 33967 is not supported in the medical record. Specifically, this code is an inpatient only procedure. The documentation shows that this service was billed in the hospital as outpatient. This means this code was inappropriately billed and is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the insertion of intra-aortic balloon assist device have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of intra-aortic balloon assist device coded 33967 provided on June 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from
May 4, 2021 to May 18, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services
were not medically necessary.
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 pay for the SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that the enrollee did not
require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional
nurse to provide medically necessary and reasonable treatment safely and effectively in a SNF from
May 4, 2021, through May 18, 2021. The documentation did not reveal evidence of complex wound care, new
enteral feedings, or other skilled nursing SNF need during these dates. The enrollee's functional level did not
require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to
provide medically necessary and reasonable treatment safely and effectively in a SNF from May 4, 2021,
through May 18, 2021. The enrollee did not require skilled nursing or skilled therapy services (or a
combination of these services) on a "daily basis" in a SNF during the dates May 4, 2021, through May 18,
2021. As a practical matter this enrollee did not require the necessary services on an inpatient basis, in a skilled
nursing facility setting May 4, 2021, through May 18, 2021.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for SNF services provided from May 4, 2021, through May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on April 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 77003 is not covered.
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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure).
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a valid primary procedure code. 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 fluoroscopic guidance rendered on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 17, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
screening test.

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 genetic
testing provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 12, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the breast you had on January 21, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not informed about this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($93.93) is less than your copayment obligation, you are responsible for the full allowed 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 $100 copayment for diagnostic radiology services (including ultrasounds).
You have been asked to pay a $100 copayment for the ultrasound. The 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 breast you had on January 21, 2021.