Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of incompetent veins for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not document clinical severity scores, and do not document compression
therapy.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not meet coverage criteria and does not support the appropriateness/medical
necessity of the procedures in question. The provider is requesting endovenous ablation of all four saphenous
veins. There is no clear documentation of lifestyle-limiting symptoms attributable to the veins in question. No
reflux is noted in the greater saphenous veins bilaterally slated for ablation. The physical examination
documented no edema in the lower extremities. There is no documentation of conservative efforts, and no
documentation of vein scoring as required.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation of incompetent veins for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), scaling and root
planing (D4342 x 4), and a filling (D2392) for tooth #5.

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The
Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan
says that scaling and root planing is covered once every 3 plan years, per quadrant. The Plan says that 2 fillings
are covered per calendar year. The Plan also says that the frequency limits for these services have been reached.

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 scaling and root planing, and
fillings are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for
scaling and root planing for all 4 quadrants that you received on April 26, 2021. The record shows that the Plan
paid for fillings on teeth #28 and 30 that you received on July 28, 2021. Additionally, periodontal maintenance
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
periodontal maintenance (D4910), scaling and root planing (D4342 x 4), and a filling (D2392) for
tooth #5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that you require additional acute care, and your bed and resources are needed for incoming COVID patients. The Plan denied your request. The Plan says you are receiving medically necessary acute and/or critical care in the current setting. An LTACH would provide no clinical advantage.
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 pay for 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 provided clinical documentation, you appear to be much more stable now and are receiving the appropriate care. It is likely that you will soon be able to be transferred to a lower level of care. Transfer to an LTACH at this point appears to be for the convenience of the physician and facility and is 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
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 services are medically necessary. The Plan denied your request. The Plan says you are currently receiving appropriate inpatient care, and an LTACH would provide no clinical advantage.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an elective right total knee arthroplasty.

You asked the Plan to pre-approve acute inpatient hospital care associated with an elective procedure. You say that you would like the inpatient care covered. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care associated with an elective procedure. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is undergoing a planned right total knee arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician would reasonably expect that the enrollee's necessary hospital care will span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care associated with an elective procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an elective right total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the repairs. We decided that the Plan does not have to pre-approve
any charge in excess of the cost of a replacement power mobility device.
You asked the Plan to pre-approve the repairs. You say that you would like reconsideration because these
repairs are medically necessary. The Plan says that Medicare does not cover the cost of repairs if these costs
exceed that of replacement.
We decided that the Plan has to pre-approve the cost of the repairs up to the cost of a replacement power
mobility device.
The Plan follows Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated
expense of purchasing or renting another item of equipment for the remaining period of medical need, no
payment can be made for the amount of the excess.
Therefore, we decided that the Plan has to pre-approve the cost of the repairs up to the cost of a replacement
power mobility device.
We also decided that the Plan does not have to pre-approve any charge in excess of the cost of a
replacement power mobility device.
The Plan follows Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated
expense of purchasing or renting another item of equipment for the remaining period of medical need, no
payment can be made for the amount of the excess.
Therefore, we decided that the Plan does not have to pre-approve any charge in excess of the cost of a
replacement power mobility device.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the betamethasone acetate injection and the office visit you had with a hand surgeon on March 9, 2021.
You asked the Plan to waive the cost sharing for the betamethasone acetate injection and the office visit you had with a hand surgeon. You say that you do not understand why you are being charged a different amount for this visit as opposed to other visits with this provider. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that you were appropriately charged a copayment for the specialist visit and 20% coinsurance for the drug you received. The Plan says that because the allowed amount for the drug is $8.15, your coinsurance for the drug is $1.37. The Plan says that the cost sharing for this visit is a bit different than other visits because the dosage of medication you received was different, resulting in different coinsurance for the drug itself. Finally, the Plan also stated that you have not been double-charged for this visit-- you are only responsible for $36.37 for this date of service.
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 Medicare Part B drugs and a $35 copayment for visits with a specialist. You have been asked to pay 20% coinsurance for the betamethasone acetate injection and ta $35 copayment for the office visit you had with a hand surgeon. The betamethasone acetate injection falls within the Medicare Part B drugs 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 cost sharing for the betamethasone acetate injection and the office visit you had with a hand surgeon on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 21, 2021.
You asked the Plan to pay for an eye refraction. You say that you were having issues with blurred vision and had difficulty seeing. You are requesting reconsideration as you did not realize it was too soon for an eye exam. The Plan denied your request. The Plan says you received the maximum amount of coverage allowed for this service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging you received on March 16, 2021.
You asked the Plan to waive the coinsurance for the myocardial perfusion imaging. You say that you were told you would not owe a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment correctly. On this date you had both a regular stress test (for which no copayment applied), and the myocardial perfusion imaging.
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, up to $75 per day for diagnostic radiology services.
The phone records show that you called and asked how much you would have to pay for a stress test. You
were appropriately advised that you would owe $0 for a stress test. However, on the date of service in
question, you also received myocardial perfusion imaging in addition to the stress test. Although you were not
charged a copayment for the stress test, you have been asked to pay 20% coinsurance for the myocardial
perfusion imaging. The myocardial perfusion imaging 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 coinsurance for the myocardial perfusion imaging you
received on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 5, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you feel the charges are too high
because the doctor was only there for a few minutes. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $250 deductible which applies to physician/practitioner services,
including doctor's office visits.
You had an office visit on January 5, 2021. The record shows that you had paid $0 toward the $250 deductible
prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $224.61.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $250 deductible which applies to physician/practitioner services,
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an
office visit was received on January 5, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for an office visit provided on January 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan you had on April 14, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that you went to the hospital and the provider did not do much for you. 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 $10 copayment for outpatient diagnostic tests. 

According to the medical records from this date of service, you had a duplex scan to evaluate your leg pain. You have been asked to pay a $10 copayment for the duplex scan. The duplex scan falls within the outpatient diagnostic 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 duplex scan you had on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided on April 12, 2021.
You asked the Plan to waive the copayment for chiropractic services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for chiropractic services. You have been asked to pay a $20 copayment for chiropractic services. Chiropractic services fall within the chiropractic 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 chiropractic services provided on April 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management services
coded 99217 provided on May 6, 2021.

You asked the Plan to pay for the observation care discharge day management services. 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 99217 is observation care discharge day management
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital
"observation status" if the discharge is on other than the initial date of "observation status."

To report services to a patient designated as "observation status" or "inpatient status" and discharged on the
same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge
Services, 99234-99236 as appropriate.]).

We find that CPT code 99217 is not supported in the medical record. Specifically, the documentation does not
include a qualifying initial observation care service in the enrollee's claim history. A qualifying initial
observation care service must be provided in order for the observation discharge to be covered. Based on this
information, we decided that Medicare rules for coverage of the observation care discharge day management
services have not been met. Therefore, we decided that the Plan does not have to pay for the observation care
discharge day management services coded 99217 provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief radiofrequency ablation services.

You asked the Plan to pre-approve the Coolief radiofrequency ablation services. You say that the enrollee has suffered from left knee pain with a level of 6/10 on a numeric scale. You say that the enrollee has failed conservative treatment. You say that physical therapy was identified as well as the functional limitations resulting from this pain. The Plan denied your request. The Plan says the requested injection services are not covered by Medicare, outside of an approved clinical research study.

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 Coolief radiofrequency ablation services. Our reviewer says that the requested Coolief radiofrequency ablation of the right knee is not medically reasonable or necessary. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery.

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 Coolief radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief radiofrequency ablation services.