Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (EEG) extended monitoring; 41-60 minutes (95812) provided on May 27, 2021.
You asked the Plan to pay for code 95812. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 95812.
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 95812 is Electroencephalogram (EEG) extended monitoring; 41-60 minutes. We find that CPT code 95812 is not supported in the medical record. Specifically, the medical records do not provide a description of code 95812. Based on this information, we decided that Medicare rules for coverage of code 95812 have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) extended monitoring; 41-60 minutes (95812) provided on May 27, 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 the enrollee meets the LTACH
admission criteria and an LTACH is the best option for her care. The Plan denied your request. The Plan says
the guidelines for coverage have not been met. The Plan says that the enrollee's care can be provided in the
current inpatient hospital.
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 was admitted to the acute inpatient setting on December 21, 2021, for
evaluation following an episode of unresponsiveness. The enrollee is noted to be ventilator dependent on
admission. A review of the provider's progress note from December 28, 2021, documents the "patient is vent
dependent and at pre-admission baseline respiratory status." 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 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 31, 2021.

You asked the Plan to pay for the ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided, there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 31, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 30, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay this copayment. You said that if you had received the medicine you needed when you asked, you would not have ended up in the ER. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the visit. This means that you have been asked to pay the correct amount based on your contract with the
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on August 6, 2021.
You asked the Plan to pay for the endodontic therapy. You say that your normal dentist could not do the root canal and there are no endodontists within 50 miles. You say that you are looking for 50% reimbursement for the procedure. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan and in-network providers are available.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473 x 2) provided on August 14, 2021.
You asked the Plan to pay for the dental services. You say that the dental office advised the procedure would be covered. You say that the dental office advised your out of pocket cost would be $274. You say that you cannot afford to pay any additional amount as you are on a very limited income. You also say that you needed these services so that you can get a bottom denture. The Plan denied your request. The Plan says the removal of torus mandibularis is not listed as a covered 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, the removal of torus mandibularis are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of torus mandibularis (D7473 x 2) provided on August 14, 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 the enrollee's condition is stabilized, and he is ready for discharge from the current acute care facility. The enrollee would benefit from continued care at an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. Records do not support the expectation that the enrollee will require long-term acute care and be in population subgroup that averages a length of stay greater than 25 days at an LTACH. The enrollee can remain in the current acute care location until such time no further acute level care is needed. A discharge to a lower level of care would not be appropriate if the enrollee has ongoing acute care needs. However, when the enrollee is medically stable and no longer requires an acute level of care, a lower level may be considered.

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 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 25, 2021.

You asked the Plan to pay for the dental service. You say that you wear Invisalign for 20 hours every day. You say that as a result, you require cleanings more often. You also say that you have only used $249 of the allotted $500 for dental services. The Plan denied your request. The Plan says prophylaxis is covered twice per plan year. 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 prophylaxis is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on February 11, 2021, and June 3, 2021. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT) (78452) provided June 23, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that the claim was listed as out of network. However it was pre-approved and the provider must be in network for your community. The Plan denied your request. The Plan says this claim was processed with the correct coinsurance applied per the Evidence of Coverage.
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 50% coinsurance for out of network diagnostic procedures and tests. You have been asked to pay $654.18 for the diagnostic service. The allowed amount was $1,308.37 and the Plan paid $654.19. The diagnostic service 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 myocardial perfusion imaging, tomographic (SPECT) (78452) provided June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 24, 2021.

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the Plan. PCDs are not covered for prevention of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric care from December 28, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services. Our reviewer says that you meet the criteria for acute inpatient mental health treatment beyond the date in question of December 28, 2021, forward. Our physician reviewer found that you have safety concerns while medication was being adjusted. It did appear that active treatment was taking place beyond the date in question. It did appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from December 28, 2021, forward.

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 pre-approve OrthoFix Trinity Elite Allograft and Bone Marrow Aspirate.
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 these services in the setting of spinal fusion surgery have 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. Orthofix trinity Allograft and bone marrow aspirate remains experimental in cases of spinal surgery. More research is needed to show safety and efficacy. Our physician reviewer found that your 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 OrthoFix Trinity Elite Allograft and Bone Marrow Aspirate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic implant (L8699).
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says the records received did not clearly explain what the prosthetic implant is for and why an unlisted code is being utilized.
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 implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan partially approved the revision surgery, but upheld the requested prosthetic implant (L8699). Detailed documentation is not evident regarding what this specific implant is or how it is medically necessary for the requested procedure. Approval cannot be made for an unknown device/implant. 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 a prosthetic implant (L8699) is not medically reasonable or 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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic implant (L8699).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth # 20 provided on May 25, 2021.
You asked the Plan to pay for the dental service. You say that the tooth in question was previously enameled by a dentist that is no longer in network. You say that your tooth had been broken off. You also say that you could not have a jagged tooth just leaving there. The Plan denied your request. The Plan says replacement crowns are covered once every 5 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. 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 dental service have not been met. Specifically, the file shows that the Plan paid for a crown for tooth # 20 that you received on January 11, 2018. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 20 provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON MRI. You say that an MRI is medically necessary. The Plan denied your request. The Plan says there is no network gap and there are available network providers who can supply an MRI.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided 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 prophylaxis (D1110) and topical application of fluoride
varnish (D1206) provided on August 9, 2021.
You asked the Plan to pay for the prophylaxis and topical application of fluoride varnish. You say that you had
a dental rider during the first three months of 2021. You also say that the coverage included in the Plan should
not have exhausted as the rider should have covered the cleaning and crown while the rider was active. The
Plan denied your request. The Plan says your benefit had been exhausted. The Plan also says that you were not
enrolled in the dental rider at the time of these 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.
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
prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on August 9, 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 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 be improving and does not require more than short-term additional acute care services that can be safely completed 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