Persius/hicric huggingface dataset:
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 LTACH would provide the enrollee the best opportunity for recovery. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee appears to be improving and requires only short-term additional acute care services that can safely be received at the current facility until more stable. 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. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered when treatment has completed.  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 a partial mandibular denture (D5226), and a partial maxillary
denture (D5225) provided by an out-of-network provider on August 19, 2021.

You asked the Plan to pay for a partial mandibular denture (D5226), and a partial maxillary denture. You say
that these services should be covered for your wife because they were covered with you. The Plan denied your
request. The Plan says D5226 and D5225 are not covered dental benefits.

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 a partial
mandibular denture (D5226), and a partial maxillary denture (D5225) provided by an out-of-network provider
on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88173, 88305) provided on July 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says there was no prior authorization for date of service July 7, 2021, and the Plan did not authorize any services for this provider. The plan also says that the provider and the facility are a non-participating provider and the referring provider involved is also a non-participating provider.  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 laboratory services (88173, 88305) provided on July 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) 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 duration of relief from the prior lumbar epidural steroid injection is unclear and there is no record of ongoing active exercise.  The Plan must follow Medicare rules. Medicare rules say that ESI's may be covered if Medicare criteria has been met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The duration of pain relief from the prior lumbar ESI is unclear and there is no record of any ongoing rehabilitation program, home exercise program, or functional restoration program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 an epidural steroid injection (ESI) 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 for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the hospital where he is now and there is no need to transfer to the LTACH at this time.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be improving to some extent but is still unstable and requires short-term additional acute care services that can safely be received at the current facility until more stable. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cystourethroscopy with stent removal performed on August 25, 2021.  You asked the Plan to waive the copayment for the cystourethroscopy. You say that this was a follow up visit and only had the stent removed, and you feel you should only owe the $35 office visit copayment. 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 $295 copayment for surgery or other services provided at an outpatient hospital.     You have been asked to pay a $295 copayment for the cystourethroscopy. Please note that this procedure is classified as a surgical procedure. Therefore, the cystourethroscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cystourethroscopy with stent removal performed on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the consultation with a dentist/physician other than the requesting dentist/physician (D9310) provided on August 13, 2021.  You asked the Plan to pay for the consultation. You say that this service should be covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.  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 consultation with a dentist/physician other than the requesting dentist/physician (D9310) provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided October 13, 2021.  You asked the Plan to pay for the limited oral exam. You say that you needed this service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the limited oral exam once per plan year.  We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on June 15, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound (76700) provided on September 16, 2021.  You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this cannot be paid without an additional modifier.  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, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76700) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-share for the extractions (D7140) provided on November 4, 2020, and the partial lower denture with a cast base (D5214) provided on December 1, 2020. You asked the Plan to waive the cost-share for the dental services. You say that you were told you should be reimbursed for this cost. The Plan denied your request. The Plan says these claims were processed correctly, and your deductible and coinsurance amounts were 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 $50 deductible for non-Medicare covered (supplemental) comprehensive dental services. Once this deductible is met, you must pay 20% coinsurance for a simple extraction of an erupted or exposed tooth (D7140) and 50% coinsurance for a mandibular (lower) partial denture with a cast base (D5214).  The provider billed the Plan $150 for each of the extractions you received on November 4, 2020. The Plan's allowed cost for each extraction is $74. This difference in cost is not your liability, and the Plan's allowed amount is the total amount that gets paid to the provider between the payments made by the Plan and yourself. You have been asked to pay $54.80 for the first extraction, because you had not yet met your $50 deductible for comprehensive dental care at the time of service. Once you paid your deductible, the remaining cost of the first extraction was $24 ($74 - $50 = $24), for which you are responsible for 20% coinsurance ($24 x 20% = $4.80; $50 + $4.80 = $54.80). You have been asked to pay $14.80 for each of the three other extractions you received on the same date. ($74 allowed cost x 20% coinsurance = $14.80). This means you are responsible for a total of $99.20 for the extractions provided on November 4, 2020.  The provider billed the Plan $1,675.71 for the partial denture provided on December 1, 2020; however, the Plan's allowed cost for this denture is $989. You are responsible for 50% coinsurance of the Plan's allowed amount for this type of denture. ($989 x 50% coinsurance = $494.50). 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 cost-share for the extractions (D7140) provided on November 4, 2020, and the partial lower denture with a cast base (D5214) provided on December 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  

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 daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the home, an assisted living facility with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  

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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.  You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested procedure is 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 pre-approve the Vertiflex Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is considered experimental and more research is needed to show its safety and efficacy.  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 Vertiflex Superion Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on October 20, 2021.  You asked the Plan to pay for the transportation services. You say that the transport from inpatient hospital stay to a skilled nursing facility was medically necessary. The Plan denied your request. The Plan says the transportation services are not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van) were contraindicated for the enrollee on October 20, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Therefore, the reviewer found that the documentation does not support that the ambulance transport on October 20, 2021 was medically reasonable and necessary for the enrollee.  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 transportation services have not been met. Specifically, the file does not show that other means of transport (such as stretcher van) were contraindicated for the enrollee on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on October 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa (J7323).  You asked the Plan to pre-approve Euflexxa. You say that the requested drug is necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the required drugs, Orthovisc, Synvisc or Synvisc One.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Euflexxa. Our reviewer says that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not show that the enrollee has tried any of the preferred drugs, Orthovisc, Synvisc or Synvisc One. The reviewer found that there is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the file does not show that the enrollee has tried and failed any of the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for speech therapy services provided on April 28, 2021.  You asked the Plan to pay for speech therapy services. You say that the patient ended hospice enrollment prior to this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.    The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare hospice benefits on April 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for speech therapy services provided on April 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services for hospital discharge day management provided on April 15, 2021.       You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services for hospital discharge day management provided on April 15, 2021.