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

 We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement, scalp, arms and/or legs identified with code 14021 provided on September 21, 2020.  You asked the Plan to pay for adjacent tissue transfer or rearrangement, scalp, arms and/or legs. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 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 14021 is adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm.  We find that CPT code 14021 is not supported in the medical record. Specifically, the operative report did not include documentation of an adjacent tissue transfer or rearrangement of the scalp, arms and/or legs; for defect 10.1sq cm to 30.0sq cm; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of adjacent tissue transfer or rearrangement, scalp, arms and/or legs have not been met. Therefore, we decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement, scalp, arms and/or legs identified with code 14021 provided on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the incontinence supply coded A4335 provided on April 5, 2021.  You asked the Plan to pay for the incontinence supply. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this code is not separately payable.  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 A4335 is incontinence supply; miscellaneous.  We find that CPT code A4335 is not supported in the medical record. Specifically, this code has a status indicator of "P". A status indicator of P means that these services are always bundled into payment for other services not specified. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the incontinence supply have not been met. Therefore, we decided that the Plan does not have to pay for the incontinence supply coded A4335 provided on April 5, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 review of the available records, the enrollee does not meet criteria for an IRF admission. There is no documentation of any nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While she may benefit from physical therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's rehabilitation needs can be easily met at a less intense and alternate level of setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 the limited oral evaluation - problem focused (D0140) provided August 3, 2021.  You asked the Plan to pay for the limited oral exam. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered under your 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 the limited oral evaluation - problem focused (D0140) provided August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided June 23, 2021.
You asked the Plan to pay for the dental services. You say that the Plan should cover these services. The Plan denied your request. The Plan says dental services are not covered under Medicare or your plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on June 24, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you paid a copayment of $50 when you went to have the CT scan. You say you are now being charged an additional $130.58 that you were not advised about. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the CT scan you had ($180.58) is less than your copayment obligation, you are responsible for the full allowed 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 $350 copayment for CT scans. You have been asked to pay a $350 copayment for the CT scan. 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 computed tomography (CT) scan you had on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve proton beam therapy as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 review of the available records, the enrollee does not meet criteria for an
IRF admission. There is no documentation of any nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While he may benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's rehabilitation needs can be easily met at a less intense and alternate level of setting such as in a Skilled Nursing 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 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 the root canal (D3310) for tooth # 9 provided on November 18, 2020.
You asked the Plan to pay for the dental service. You say that you have only received a reimbursement of $130.29 for this root canal. You say that you received $2,000 reimbursement for the other 2 root canals you received. You also say that you do not understand why you have not received the same reimbursement for this one. The Plan denied your request. The Plan says root canal is not listed as a covered dental 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 root canal is not among those covered under this benefit. Additionally, the root canal you are asking the Plan to pay for involves the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) for tooth # 9 provided on November 18, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 review of the available records, the enrollee does not meet criteria for an IRF admission. There is no documentation of any nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While she may benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's rehabilitation needs can be easily met at a less intense and alternate level of setting such as in a Skilled Nursing 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided May 25, 2021.
You asked the Plan to pay for the ambulance response with no transport. You say that you did not realize that the ambulance services would be denied if you did not take the transport to the hospital. The Plan denied your request. The Plan says ambulance services are not covered when there is no transport.
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 May 25, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The trip report in this case shows that you were feeling better and refused transport to the hospital and thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided May 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 29, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a routine procedure and nothing abnormal was found. 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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy on July 29, 2021, due to findings found
on advanced imaging. Therefore, you are responsible to pay the $450 copayment.
You have been asked to pay a $450 copayment for a colonoscopy. A colonoscopy 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 colonoscopy provided on July 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 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 more stable but still requires additional short-term acute care services that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections.
You asked the Plan to pre-approve SI joint injections. You say that your physician said there may be damage or inflammation of the nerves, which is why this procedure was recommended. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you have not had tests showing that your pain is coming from the sacroiliac joint.
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 SI joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for use of SI joint block injections include that the patient has tried and failed 4-6 weeks of conservative therapy including physical therapy, a home exercise program, and medication management. There should be a clinical picture suggesting of sacroiliac injury and/or disease. At least 3 positive examination findings of SI joint dysfunction should be present on physical examination. There is no documentation of SI joint provocative testing being done.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections.
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 more stable and responding to current treatment and only requires short-term additional acute care that can be safely administered 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 19, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit for evaluation and management of a new
patient (99205) provided on February 18, 2021.
You asked the Plan to pay for the outpatient visit. You say that the enrollee had revoked their hospice benefit
prior to the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of
election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's
responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures
for a Medicare Advantage member on hospice.
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 February 1, 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 the outpatient visit
for evaluation and management of a new patient (99205) provided on February 18, 2021.