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

 We decided that the Plan does not have to pre-approve continuation of SNF services.  

You asked the Plan to pre-approve continuation of SNF services. You say that you are not able to fully care for yourself at this time, and you would like to continue to stay at the SNF and work with therapists to increase strength and balance. The Plan denied your request. The Plan says continuation of SNF services 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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective, you received oral medications. You had stable vital signs. Your lungs were clear. Your appetite was good. Regarding rehabilitation services, you received physical therapy and occupational therapy. You were at a standby assist to contact guard assist level for functional mobility including gait to 175 feet with a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 1, 2021, to August 12, 2021.  You asked the Plan to waive the copayment for the inpatient stay. You say that you were discharged from the hospital three weeks prior to this admission with the same issue and feel that both admissions should only have the one copayment. 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 $395 copayment for each of the first five days of an inpatient hospital stay. There is a $0 copayment for additional days. You have been asked to pay a $1,975 copayment for an inpatient stay which exceeded five days ($395 x 5 = $1,975). The Plan has paid their portion of the cost and processed this inpatient admission as a separate admission. 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 inpatient hospital admission and services provided from August 1, 2021, to August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 9, 2021  

You asked the Plan to pay for the problem focused limited oral evaluation. You say that your infection was out of control and you needed this visit to get the situation under control. You also say that this was a visit and not a routine exam. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  

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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 17, 2021 and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 9, 2021
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self administered drugs provided on March 3, 2020, through March 7, 2020.  You asked the Plan to pay for the self administered drugs. You say that you would like reconsideration because the hospital reviewed and dispensed all of the medications the over-the-counter products should have been covered. The Plan denied your request. The Plan says the drugs in question are not covered under the member's contract under any normal circumstances.  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 pay for the self administered drugs provided on March 3, 2020, through March 7, 2020.   Benefits for the self administered drugs 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: 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available 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. 

 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Signatera molecular residual disease (MRD) assessment rendered on April 30, 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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRD testing is covered when specific criteria are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was diagnosed with stage 1 rectal cancer (moderately-differentiated adenocarcinoma) in August of 2019. The documentation does not support that the enrollee has a diagnosis of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The documentation is insufficient to support that the testing was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Signatera molecular residual disease (MRD) assessment rendered on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a fluoroscopy procedure (76000) provided on June 29, 2021.  

You asked the Plan to waive the copayment for a fluoroscopy. You say that the procedure at issue was needed during your surgery as this is how the doctor knew where to proceed with injections. The Plan denied your request. The Plan says the correct copayment was 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 $30 copayment for Medicare-covered X-ray and ultrasounds.   

A copayment is a fixed amount charged on a per-service basis. You have been asked to pay a $30 copayment for a fluoroscopy. A fluoroscopy 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 a fluoroscopy procedure (76000) provided on June 29, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) services.  

You asked the Plan to pre-approve RFA services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that before RFA services will be approved, there must have been 2 medically reasonable and necessary MBBs performed. In addition, these MBBs must have provided a consistent minimum of 80% sustained relief of pain.   

We looked at the file and Medicare rules. Although the file indicates that 2 MBBs have been performed, the amount of pain relief these injections provided is not indicated. Without this information, the criteria for the RFA have not been met. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on August 11, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the psychotherapy services. You say that you were under the impression that the services would still be covered after changing your insurance to this Plan. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

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 requested 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 the individual psychotherapy services (90837) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the post removal (D2955) and local anesthesia (D9215) provided on June 21, 2021.  

You asked the Plan to pay for the post removal and local anesthesia. You say that these services were necessary, and you believe they should be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.  

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 post removal (D2955) and local anesthesia (D9215) provided on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar (CPT code 63267) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee does not meet any of the criteria to be approved for an out-of-network visit. The Plan states the notes the doctor sent in does not show the medical necessity for the requested procedure, this is not a neurosurgical emergency, and there is no weakness or numbness documented associated with the enrollee's pain.

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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar (CPT 63267) in this case, is not medically reasonable or necessary. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar (CPT 63267) to be provided by an out-of-network provider is not medically reasonable or necessary. The service is not urgent or emergent that it needs to performed out-of-network. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar (CPT code 63267) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on July 27, 2021.

You asked the Plan to pay for a tooth extraction. You say that the tooth extraction should be covered under your preventative benefit, because if you had not had the tooth extracted then you would have had other issues. The Plan denied your request. The Plan says you did not elect to purchase the retiree group Enhanced Plan that would cover teeth extractions and therefore the service is not a covered benefit with your Plan.

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. The records show that you elected a Plan that only covers preventative and diagnostic dental service benefits. Your dental Plan does not cover the service requested. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for discharge day management services (99239) provided on April 18, 2021.  

You asked the Plan to pay for the discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99239 is hospital discharge day management; more than 30 minutes.  

We find that CPT code 99239 is not supported in the record. Specifically, the documentation does not support that more than 30 minutes of discharge day management services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management services (99239) provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown provided on September 17, 2021.  

You asked the Plan to pay for the crown. You say that the provider informed you the crown was approved. The Plan denied your request. The Plan says the service is denied because the root canal treatment on tooth #18 does not meet clinically acceptable standards for root canal therapy.  

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 pay for the crown. Our reviewer says that due to the poor prognosis of the inadequate root canal fill on tooth #18, the criteria for coverage for the coverage for a crown restoration 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 pay for the crown provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for shoe inserts (L3020), provided on September 28, 2020.  

You asked the Plan to pay for foot orthotics. You say that the items are medically necessary. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for shoe inserts (L3020), provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on September 14, 2021. 

 You asked the Plan to waive the copayment for the eye exam. You say that you went for a routine eye exam. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for each visit to diagnose or treat a disease or condition of the eye.  

 The record shows that you were seen for a specific condition (blurry vision). For this reason, the exam is then considered a diagnostic exam. Therefore, you have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the Vision 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 a diagnostic eye exam provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology rendered on June 11, 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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records do not support that 
the special stains were medically necessary for the enrollee. There are diagnosis and service requirements that 
must be documented in the available patient data to explain and support multiple infectious detection tests for 
common nail/feet concerns. Given the lack of this documentation, the testing was not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the molecular pathology rendered on June 11, 2021.