Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rural health clinic telehealth services rendered on January 4, 2021 and April 9, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. We looked at the file and Medicare rules. Billed procedure code G2025 (payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally qualified health center [fqhc] only) has a status indicator of X and is statutorily excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the rural health clinic telehealth services rendered on January 4, 2021 and April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skin biopsy and testing provided on
September 9, 2021.
You asked the Plan to waive the copayment for the biopsy and testing. You say that you do not know why the
procedure was denied. The Plan denied your request. The Plan says you have been charged the correct cost
sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for outpatient surgery in an outpatient hospital.
You have been asked to pay a $300 copayment for the biopsy and testing. The biopsy and testing fall within the
Outpatient Surgery and Other Medical 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 skin biopsy and
testing provided on September 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) home health physical therapy (PT) visits.
You asked the Plan to pre-approve 4 home health PT visits. You say that the requested visits are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of these services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 4 home health PT visits. Our reviewer says that 4 home health PT visits are not medically necessary. Our physician reviewer found you do not have documented, ongoing, skilled PT needs. The requested, ongoing, home health PT services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) home health physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while the enrollee may require skilled services, these services are not medically necessary at a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Electroretinography (92273) provided
on August 25, 2021
You asked the Plan to waive the copayment the Electroretinography. You say that the services should be
covered as you were only there for five minutes. The Plan denied your request. The Plan says the cost-sharing
applied correctly based on the services provided.
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 Vision care.
You have been asked to pay a $20 copayment for an Electroretinography. The Plan's contract states that the
copayment for vision services is only waived for glaucoma screenings and diabetic retinal exams.
Electroretinography's fall within the Vision care 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 Electroretinography (92273) provided on August 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and topical application of fluoride varnish (D1206) provided on September 30, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays and topical application of fluoride varnish. You say that you were not advised that the treating provider was OON before you received these services. The Plan denied your request. The Plan says these services are not covered expenses under your dental 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, 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 complete series of intraoral x-rays (D0210) and topical application of fluoride varnish (D1206) provided on September 30, 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 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. 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 medically necessary. Our physician reviewer found you were admitted to the hospital for agitation, hallucinations, dementia, and high blood pressure. You are now medically stable with no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 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 testing is not covered.
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. The test at issue in this appeal, SelectMDx, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wheelchair swingaway and repair provided on November 22, 2021.
You asked the Plan to waive the coinsurance for the wheelchair swingaway and repair. You say that you do not want to pay the cost of repairs for the wheelchair since it has had many issues over the last year. The Plan denied your request. The Plan says the correct coinsurance was applied.
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% coinsurance for durable medical equipment (DME) and related supplies, such as wheelchair parts.
Item
Allowed Amount
20% Coinsurance
Manual Swingaway (E1028)
$145.60
$29.12
Repair Service (K0739)
$31.94
$6.38
Total:
$35.50
You have been asked to pay $35.50, which is 20% of the allowed amount for the wheelchair swingaway and repair. The wheelchair swingaway and repair falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a wheelchair swingaway and repair provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2020.
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 services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in the ambulatory surgical center
setting and should have been billed with POS code 24. Therefore, we decided that the Plan does not have to
pay for the laboratory services rendered on December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient mental health care for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that this treatment is medically necessary. The Plan denied your request. The Plan says that based on the records provided, this level of care is not necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The case file did not contain medical records for review. Therefore, we decided that the Plan has to pre-approve inpatient mental health care for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that transfer to a SNF is medically necessary. The Plan denied your request. The Plan says the SNF services are 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while you may require skilled nursing and/or skilled therapy services, the services are not medically necessary at a skilled nursing facility level of care, at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve transfer to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified occupational therapist (G0152) and direct skilled nursing services of a registered nurse (RN) (G0299) provided from March 15, 2021, to April 7, 2021.
You asked the Plan to pay for the services performed by a qualified occupational therapist and direct skilled nursing services of a RN. You say that other patients' claims have processed despite the RAP claim being received in 5 days. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care. The RAP claim was submitted on April 27, 2021.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services performed by a qualified occupational therapist and direct skilled nursing services of a RN have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, March 15, 2021. Therefore, we decided that the Plan does not have to pay for the services performed by a qualified occupational therapist (G0152) and direct skilled nursing services of a registered nurse (RN) (G0299) provided from March 15, 2021, to April 7, 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 LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of LTACH 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 medical record does not indicate that the enrollee requires services that he is not
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are
not satisfied.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
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 Botox is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of incisional hernia. The hernia measures greater than 10 centimeters in width and has multiple defects. The requested Botox is not covered for this indication. The services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
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 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. 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 medically necessary. Our physician reviewer found you were admitted to the hospital
on February 2, 2022 after a fall and underwent right hip fracture surgical repair on February 3, 2022. The
progress note dated February 8, 2022 states you need minimal assistance with standing up, bed to chair
transfers, and sitting down. You need assistance with walking 45 feet using a rolling walker. You do not
require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per
week of rehabilitative services and regular physician evaluation. The IRF services are 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 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: 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 you would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not
meet Medicare criteria for coverage of the IRF 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 the complexity of the member's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no
complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
There is not a reasonable expectation that this member will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller wheelchair accessory (E2377),
a harness upgrade (E2313), an electronic connection accessory (E2311) and a power seat elevation system
(E2300).
You asked the Plan to pre-approve an expandable controller wheelchair accessory, a harness upgrade, an
electronic connection accessory and a power seat elevation system. You say that these items are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of these items.
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 an expandable controller wheelchair
accessory, a harness upgrade, an electronic connection accessory and a power seat elevation system. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that you do not require a separate display (i.e., for alternate control
devices), other electronic devices or an attendant control. You have 3 power options of tilt, recline, and power
elevating leg rests but you do not need to control the power options through a joystick. Your upper extremity
strength and function support that you can control any power options through their own switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller wheelchair accessory, a harness upgrade, an electronic
connection accessory and a power seat elevation system. have not been met. Therefore, we decided that the
Plan does not have to pre-approve an expandable controller wheelchair accessory (E2377), a harness upgrade
(E2313), an electronic connection accessory (E2311) and a power seat elevation system (E2300).