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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says that criteria for admission to the LTACH have not been met. The enrollee's needs are being met in the current acute setting. The LTACH would provide no additional services.

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 only requires short-term additional acute care services for stabilization which can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, the request for transfer to an LTACH will not be considered medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new shower unit.
You asked the Plan to pre-approve a new shower unit. You say that your current shower tub is to high and you would benefit from a new shower unit. The Plan denied your request. The Plan says the requested item is a convenience item and does not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a new shower unit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized wheelchair.

You asked the Plan to pre-approve a motorized wheelchair. You say that the item would improve your quality of life. The Plan denied your request. The Plan says DME is not covered for use outside of the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a motorized wheelchair.
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 May 3, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you thought the Plan would pay more for this service. You also say that you are on a limited income and were not expecting a charge so high. The Plan denied your request. The Plan says this service is not covered.

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 problem focused limited oral evaluation (D0140) provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222) and 2 additional units of deep sedation (D9223).

You asked the Plan to pre-approve the dental services. You say that you would like to get all of your teeth removed at once. You say that you are petrified of needles going in your mouth. You say that you cannot chew properly. You also say that you need to get this done quickly and you need anesthesia to do that. The Plan denied your request. The Plan says deep sedation 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 requested deep sedation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222) and 2 additional units of deep sedation (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and panoramic x-ray (D0330) provided on May 20, 2021.
You asked the Plan to pay for the consultation and panoramic x-ray. You say that you were not aware that this treating provider was out-of-network. You also say that it seems logical that if your in-network dentist refers you to an oral surgeon, the oral surgeon is an in-network provider. The Plan denied your request. The Plan says the consultation is not a covered benefit under your dental plan. The Plan also says that panoramic x-ray 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, consultation (D9310) is not among those covered under this benefit. The contract says that panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on March 30, 2021 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) and panoramic x-ray (D0330) provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650 X 2), for the enrollee.
You asked the Plan to pre-approve the services. You say that the service medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show that the enrollee does not have a condition for which this treatment is medically necessary. The Plan states the enrollee has not had maximal medical management. The Plan states there is no adequate documentation of any form of neurosurgical evaluation that indicate that the enrollee is not a surgical candidate.
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. physician reviewer found the enrollee's magnetic resonance imaging (MRI) (of the lumbar spine) showed no evidence of nerve root injury/impingement. Nor was there other evidence of a nerve root injury. The enrollee otherwise does not have another diagnosis for which the LCD supports a trial of a spinal cord stimulation (SCS). For these reasons the request would not be 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650 X 2), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on April 29, 2021.
You asked the Plan to waive the coinsurance for an office visit. You say that you disagree with the increase in charges for the visit because this was an annual wellness visit where you discussed medications and your conditions. 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 15% coinsurance for physician/practitioner services, including doctor's office visits. You had an office visit on April 29, 2021. The record shows that services beyond an annual wellness visit took place. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is
$268.93 and 15% of that is $40.34. You have been asked to pay the total coinsurance amount of $40.34 for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services.
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 only requires short-term additional acute care services which can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, request for a transfer to an LTACH is considered not medically necessary at this time. Transfer to a lower level of care 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 services are not medically necessary. Our physician reviewer found the enrollee has pulmonary nodules found on imaging and is a non-smoker. A chest CT from 2016 showed nodules less than four millimeters. A CT chest from November of 2020 showed a new right lower lobe three millimeter nodule and increased three millimeter left lower lobe nodule. Given that the nodules are relatively stable and less than four millimeters, frequent imaging is not recommended. The repeat CT is not 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 pre-approve a repeat computed tomography (CT) scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from March 9, 2021, through April 7, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continued SNF 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. long term care). 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 pay for continuation of skilled nursing facility (SNF) services provided from
March 9, 2021, through April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel testing provided on January 7, 2021.
You asked the Plan to pay for the testing services provided. You say that the service is covered for Covid
testing. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
We looked at the file and the rules. The respiratory panel is not a covered coronavirus test. The testing panel
was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for the respiratory panel testing provided on January
7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on June 30, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because the X-ray results were unreadable, and you had to have them retaken. 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 $35 copayment for each X-ray. You have been asked to pay a $35 copayment for an X-ray. An X-ray 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 an X-ray provided on June 30, 2021.
We note your complaint that your X-ray results were unreadable. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on April 1, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that no one has explained the charges to you or that you would owe anything for treatments. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on April 1, 2021. The total allowed amount is $1,291.20 and 20% of that is $258.24. 

You have been asked to pay the total coinsurance amount of $258.24 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription 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 coinsurance for Medicare Part B drugs provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass deluxe frames, progressive lenses and miscellaneous vision services provided on January 11, 2021.
You asked the Plan to pay for eyeglass frames and vision services. You say that you thought the provider was in-network and figured they would be cheaper. The Plan denied your request. The Plan says coverage cannot be provided if purchased through an out-of-network provider.
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 you have a $150 allowance for eyewear every twelve (12) months with the Plan's specified routine vision provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and vision services have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass deluxe frames, progressive lenses and miscellaneous vision services provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded as 87798 provided June 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the services as billed are not supported by the documentation.
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 87798 is Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.
We find that CPT code 87798 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 87798 provided June 2, 2020.