Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from October 15, 2020, through October 17, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that the medical records demonstrate the enrollee's emergency medical condition was stabilized by 12:31 p.m. on October 16, 2020 such that it met the Medicare standard for transferability, namely that within reasonable medical probability no material deterioration of her condition was likely to result from or occur during transfer had the enrollee had been transferred to a Plan facility at 12:31 p.m. on October 16, 2020.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 inpatient admission. Our reviewer says that the inpatient care at the non-Plan facility was not medically necessary. Our physician reviewer found the enrollee was a then 74-year-old male with a significant history of chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) status post multiple stents, who arrived at the emergency department (ED) on October 15, 2020 via ambulance for a chief complaint of chest pain that radiated to his neck with associated nausea and vomiting. Electrocardiogram revealed acute ST-elevated myocardial infarction (STEMI), code STEMI was activated, and he was emergently taken to the cardiac catheterization lab (cath lab) and underwent successful percutaneous transluminal coronary angioplasty (PTCA). Post cardiac catheterization, the enrollee was in no acute distress with no complaints of chest pain and hemodynamically stable. On October 16, 2020 at 11:52 a.m., the enrollee is noted to be "pain free" and "stable for transfer to tele floor." By 12:31 p.m. the Cardiology progress note stated the enrollee was "reasonably stable, hemodynamics good" and was "will transfer to Plan facility for further care." The review indicates that by 12:31 p.m. on October 16, 2020 the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. The post-stabilization care services beginning 12:31 p.m. at the non-Plan facility were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 

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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from October 15, 2020, through October 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health bathing aid three times a week for one month.  You asked the Plan to pre-approve home health bathing aid three times a week for one month. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 home health bathing aid three times a week for one month. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. As you are not receiving skilled nursing or skilled therapy the criteria of home health aide services per Section 50.2 is not met and the request for home health aide services is not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health bathing aid three times a week for one month have not been met. Therefore, we decided that the Plan does not have to pre-approve home health bathing aid three times a week for one month.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the partial framework repair (D5622).  You asked the Plan to pre-approve the partial framework repair (D5622). The Plan denied your request. The Plan says the resin-based composite was approved and the partial framework repair is not a covered 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 partial framework repair (D5622) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the partial framework repair (D5622).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an E2300 power seat elevation system for the enrollee.  You asked the Plan to pre-approve this accessory. You say that a power seat elevation system is necessary for the enrollee. The Plan denied your request. The Plan says this accessory is not covered by Medicare.  The Plan must follow Medicare rules. Medicare does not cover this accessory under any circumstance.  Therefore, we decided that the Plan does not have to pre-approve an E2300 power seat elevation system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator is necessary because your portable tanks are heavy. The Plan denied your request. The Plan says you currently have equipment for use in the home that meets your needs.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have oxygen tanks for use in the home. Oxygen tanks serve the same purpose as a portable oxygen concentrator. Medicare does not cover additional equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network immunotherapy.  You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network immunotherapy.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on August 3, 2021, by an OON provider.  You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  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 the drug testing provided on August 3, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 30, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that the enrollee did not call the ambulance. You say the ambulance personnel monitored the enrollee's glucose, and the enrollee refused transport. The Plan denied your request. The Plan says the Medicare guidelines say that the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 30, 2021.  You asked the Plan to pay for the TEMPR device. You say that the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 30, 2021 was medically necessary. The Plan denied your request. The Plan says the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 30, 2021 was not 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 pay for the TEMPR device. Our reviewer says that the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 30, 2021 was not medically necessary. Our physician reviewer found the enrollee has polyneuropathy. She received transcutaneous electrical modulation pain reprocessing (TEMPR) therapy, also known as Scrambler therapy. This is considered experimental/investigational therapy.  Therefore, the request is deemed not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TEMPR device have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on December 30, 2020 to January 3, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of procedure code J15.6 and DRG 179.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with diagnosis code J15.6 (pneumonia due to other gram-negative bacteria) and DRG 179 (respiratory infections and inflammations without cc/mcc). 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 these services. Our reviewer says that the submitted records do not support the billing of procedure code J15.6 and DRG 179. Our physician reviewer found the enrollee presented to the emergency department (ED) with complaints of bilateral shoulder and left upper chest wall pain. She was afebrile in the ED with oxygen saturation of 97 to 100 percent on room air. A computed tomography (CT) scan of the chest noted ground glass opacities within the right middle lobe and lingula and the enrollee was placed on antibiotics for pneumonia. While the enrollee was noted to be immunocompromised and the physician documented a diagnosis of gram-negative pneumonia in the query on January 02, 2021, review of the record found no microbiological confirmation of a gram-negative organism. Therefore, there was insufficient objective clinical evidence to validate gram-negative pneumonia. The billing of diagnosis J15.6 and DRG 179 is not supported.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered on December 30, 2020 to January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a fourth spinal injection for the enrollee.  You asked the Plan to pre-approve a fourth injection. You say that this treatment is medically necessary, and the three-month window has passed. The Plan denied your request. The Plan says the enrollee received spinal injections on June 23, 2021, August 17, 2021, and September 14, 2021. The Plan states the enrollee is not currently eligible for this treatment.   The Plan must follow Medicare rules. Medicare rules say no more than 3 epidurals may be performed in a 6-month period. This would be the enrollees fourth injection withing 6 months. Therefore, we decided that the Plan does not have to pre-approve a fourth spinal injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150) and the alveoloplasty not in conjunction with extractions (D7321) provided from June 24, 2021, to July 20, 2021.  You asked the Plan to pay the in network rate for the dental services. You say that the dental office advised they were in network with your plan. You also say that you are now being told they are out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays the provider. The Plan also says that you did call to verify your benefits but did not verify the provider's eligibility.  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 the services are listed as covered, dental services received out of network are subject to a higher cost shar amount. Additionally, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150) and the alveoloplasty not in conjunction with extractions (D7321) provided from June 24, 2021, to July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 73100 provided on June 26, 2021.  You asked the Plan to pay for the x-ray services. 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 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, we have confirmed that code 73100 for the x-ray services is a column II code to column I code 73110. 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 the x-ray services coded 73100 provided on June 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) services.  You asked the Plan to pre-approve the CT scan. You say that the enrollee has lost weight and the CT scan is ordered to look for the cause. The Plan denied your request. The Plan says the requested CT is 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 the CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no specific clinical rationale for the requested CT scan. There is no documentation of the exam by her provider, blood tests, chest x-ray and other tests.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on July 6, 2021, or pay for the screening mammogram you had on June 28, 2021.

You asked the Plan to waive the copayment for the primary care office visit. You say that your doctor sent you for this mammogram and he did not ask when you had had your last one. You said that the doctor's office didn't do what they were supposed to do, so you shouldn't have to pay for these services. The Plan denied your request. The Plan says you were charged the correct copayment for the office visit. The Plan also says that you exhausted your annual mammogram benefit on October 27, 2020, and you were not eligible for another one on June 28, 2021.

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 primary care doctor visits. 

You have been asked to pay a $20 copayment for the primary care office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. In addition, your contract explicitly states that you are only covered for one screening mammogram every 12 months. You already received a covered screening mammogram on October 27, 2020, so you would not be eligible for another one until October 27, 2021. As a Plan member, it is your obligation to follow the Plan's rules. Because the Plan clearly disclosed this frequency limitation to you, the Plan cannot be obligated to cover this mammogram. Therefore, we decided that the Plan does not have to waive the copayment for the primary care office visit you had on July 6, 2021, or pay for the screening mammogram you had on June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide visits (G0156).  You asked the Plan to pre-approve home health aide visits. You say that your needs have not changed so your services should not change. The Plan denied your request. The Plan says the requested home health aide visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 home health aide visits. Our reviewer says that the requested home health aide visits are not medically necessary. Our physician reviewer found the provided documentation indicates that you do ot have documented, acute, skilled needs. The documentation does not show that commiserate home health aide services are required to assist in treatment of an acute illness or injury. The reviewer found that your home health needs appear to be custodial and long-term. Therefore, the reviewer found that the requested home health aide services are not medically necessary, reasonable or coverable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide visits have not been met. Specifically, the file indicates that your home health needs appear to be custodial and long-term. Therefore, we decided that the Plan does not have to pre-approve home health aide visits (G0156).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-rays provided on July 2, 2021, to July 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the x-rays. You say that you were unaware you needed to see an in-network doctor for your follow-up appointments after your surgery. The Plan denied your request. The Plan says no prior authorization was obtained.  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. The record shows x-rays do not apply to the 90-day global benefit period. Therefore, we decided that the Plan does not have to pay for the x-rays provided on July 2, 2021, to July 27, 2021, by an out-of-network (OON) provider.