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 for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH
admission. The Plan denied your request. The Plan says that the enrollee is not medically stable for transfer to
an LTACH.
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. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided form December 10, 2020, to December 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided form December 10, 2020, to December 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (S9122) and ground mileage (A0425) provided from April 16, 2021, to April 30, 2021.
You asked the Plan to pay for the home health and transportation services. You say that the services should be covered by the Plan. The Plan denied your request. The Plan says the home health provider in this case is not enrolled in Medicare. The Plan says that payment cannot be made to a provider that is not enrolled in Medicare. The Plan also says there are home health providers that participate with Medicare available to provide these services.
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 the home health aide services (S9122) and ground mileage (A0425) provided from April 16, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that these should be covered to prevent blood clots from your surgery. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the patient needs physical therapy so she can go
home. The Plan denied your request. The Plan says that your request does not show that the enrollee has skilled
nursing or therapy needs that need to be provided daily as an inpatient only status.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on May 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our coder 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 services. Our reviewer says that the use of code 97530 is not supported by the records provided. Our reviewer found that the documentation supports an occupational therapy visit in the home setting. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for these services. Therefore, CPT 97530 would not be covered.

We looked at this coder'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 pay for the services (97530) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), periapical x-ray (D0220), and extraction (D7210) provided from May 28, 202, to June 21, 2021.

You asked the Plan to reimburse you for the dental services. You say that you were under the impression that the provider was in network. You say that the combination of these bills is a lot for someone on a fixed, limited income. You also say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are 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, dental services received out of network are not covered under this benefit. Additionally, the limited oral evaluation is not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), periapical x-ray (D0220), and extraction (D7210) provided from May 28, 202, to June 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 12, 2020, to December 13, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the facts support the independent physician determination given the grave condition of the enrollee, mandating admission. You also say that the inpatient stay was medically necessary at the acute level of care. The Plan denied your request. The Plan says these services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 12, 2020, to December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) on the occlusal surface of tooth #14 provided on June 29, 2021.
You asked the Plan to pay for the resin-based composite. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says the number of occurrences this procedure was performed has exceeded the contract limits.
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, fillings are limited to 1 per tooth surface per year. The record shows that you received a filling (amalgam) on the occlusal surface of tooth #14 on January 15, 2021 and your fillings benefit for the occlusal surface of tooth #14 has been exhausted.
Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) on the occlusal surface of tooth #14 provided on June 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on March 13, 2021.
You asked the Plan to pay for the rotary wing air transport and mileage. You say that you believe the on-site medical personnel had made the best call because they suspected the enrollee may have had a broken bone and she was in immense pain. The Plan denied your request. The Plan says the enrollee did not require air ambulance transport. The Plan also says that there was no life-threatening condition requiring air ambulance transport per Medicare rules.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 rotary wing air transport and mileage. Our reviewer says that the air ambulance was not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation supports that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. She had severe pain, inability to ambulate and had a suspected right hip fracture. Our reviewer found that the documentation does not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Ground transport would have sufficed for the enrollee's condition. She was hemodynamically stable and could have been treated safely with ground transport. Our physician reviewer also found that the documentation does not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. 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 rotary wing air transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on March 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bone replacement grafts for ridge preservations (D7953), and two additional surgical extractions (D7210 x2) provided on May 21, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, bone replacement grafts. You say that you were advised that this treating provider was in-network. You also say that you did not do anything wrong and should not be held responsible. The Plan denied your request. The Plan says these services are 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, problem focused limited oral evaluation and bone replacement graft are not among those covered under this benefit. The contract says that extractions are limited to three procedure codes per calendar year. The record shows that you received five surgical extractions (D7210 x5) on May 21, 2021, three of which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bone replacement grafts for ridge preservations (D7953), and two additional surgical extractions (D7210 x2) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99401) provided to you on June 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee Schedule indicates that the code in question is not covered by Medicare. We looked at the file and Medicare rules. Code 99401 is assigned a status indicator of "N" under the Physician Fee Schedule, which means that this code is not covered by Medicare. 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 pay for the services (99401) provided to you on June 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground
mileage (A0425) provided on May 27, 2021.
You asked the Plan to pay for the ambulance services. You say that the services should be covered. 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 May 21, 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 non-emergency
ambulance transport (A0428) and ground mileage (A0425) provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 a diagnosis of recurrent adenosarcoma of the uterus with bony metastases. Based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the Neulasta meets Medicare criteria for medically reasonable and necessary for the enrollee, as the chemotherapy regimen with Yondelis does not carry a risk of febrile neutropenia of at least 10 percent. The Neulasta is not safe and effective and reasonable and 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 Neulasta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services provided on August 3, 2020, to August 5, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the occupational therapy services. You say that the services were medically necessary. 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 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
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the occupational therapy services provided on August 3, 2020, to
August 5, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.