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

We decided that the Plan does not have to pay for the emergency department services (99282) provided on July 29, 2021.

You asked the Plan to pay for the emergency department services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says payment has denied correctly based on Medicare coding rules.

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 99282 is a column II code to column I code 99283. 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 emergency department services (99282) provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lift chair (E1399), provided on April 1, 2021.

You asked the Plan to pay for a lift chair. You say that the item should be covered. The Plan denied your request. The Plan says you have not yet met your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to durable medical equipment (DME) and related supplies. 

The item or service you asked the Plan to pay for falls within the benefit category durable medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to durable medical equipment (DME) and related supplies. This cost sharing is a contractual obligation that had not been met at the time a lift chair was received on April 1, 2021. Therefore, we decided that the Plan does not have to pay for a lift chair (E1399), provided on April 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that your doctor believes this is essential to keep your pain at a lower level. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is correct, because the record does not show that ongoing physical therapy will result in improvement in your condition. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior extensive and repetitive therapy visits for your condition. The records do not demonstrate that the unique skills of a professional therapist are required to
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. You have been instructed in and are compliant with a home exercise program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services (A0431, A0436) provided on December 8, 2020.
You asked the Plan to pay for air ambulance transport. You say that these services were medically necessary, and this claim should be paid. The Plan denied your request. The Plan says the criteria for coverage of air ambulance transportation are not met, and the requested services were not medically necessary.
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 air ambulance transport. Our reviewer says that the air ambulance services were not medically necessary. Our physician reviewer found the provided medical records show that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. However, there is no documentation that the enrollee's condition was such that the time needed to transport them by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Records document that the enrollee's pain was controlled, and vital signs were stable; she was reported to be able to ambulate to and from the air ambulance at the time of transport. While the hospital transfer was necessary, as documentation supports that the transferring hospital did not have adequate facilities to provide the necessary care, the records do not support that it was critical for the enrollee to be transported by air ambulance as opposed to ground ambulance as defined by Medicare criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation services (A0431, A0436) provided on December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).

You asked the Plan to pre-approve Evenity. You say that the drug is medically necessary. The Plan denied your request. The Plan says the criteria for this drug requires a diagnosis of post-menopausal osteoporosis (bone loss after menopause) AND one of the following; history of bone fracture, unable to take oral therapy for osteoporosis OR had a trial of oral medication for the treatment of steoporosis (bone loss) and now has an intolerance or contraindication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Specifically, this member is not post-menopausal. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a urology telehealth specialist visit provided on November 23, 2021.

You asked the Plan to waive the copayment for a telehealth specialist visit. You say that you did not have a phone conversation or virtual visit on this day. 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 $30 copayment for each telehealth specialist visit.

You have been asked to pay the allowed amount of $14.26, which is less than the $30 copayment for a telehealth specialist visit. A telehealth specialist visits falls within the Telehealth Services benefit category. The record shows the telehealth specialist visit was provided to you. 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 urology telehealth specialist visit provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on October 4, 2021.
You asked the Plan to pay for the dental services. You say that you went to the dentist because your teeth hurt. You also say that the dentist said they needed to do an x-ray to figure out why your tooth hurt. The Plan denied your request. The Plan says the claim was processed correctly.
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, the frequency limits have been exceeded. The Evidence of Coverage says that 1 comprehensive or periodontal evaluation is covered every 3 years, and 1 complete series or panoramic x-ray is covered every 5 years. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on March 20, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that no edema has been found as you have been wearing compression hose. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the prophylaxis. We decided that the Plan does not have to pay for the 2 fillings.
You asked the Plan to pay for the prophylaxis. You say that you do not understand why you are given $2,250 for dental services for the year but the services you receive are not covered. You also say that periodontal cleaning is allowed. The Plan denied your request. The Plan says periodontal maintenance is covered once per 12 months. The Plan also says the frequency limit has been exceeded.
We decided that the Plan has to pay for the prophylaxis.
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. Specifically, the file does not support that the frequency limit for prophylaxis has been exceeded. The Evidence of Coverage states that 2 prophylaxis are covered per calendar year. The provided documentation does not support the frequency limit has been exceeded. Therefore, we decided that the Plan has to pay for the prophylaxis provided on August 30, 2021.
We also decided that the Plan does not have to pay for the 2 fillings.
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 2 fillings provided on September 16, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
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 improving and only short-term additional acute care services is needed that can safely be administered at the current facility until more stable and when wound care needs are appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment is 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement walker.
You asked the Plan to pre-approve a replacement walker. You say that it is necessary for you to receive a new walker. The Plan denied your request. The Plan says a replacement walker will not be provided as it is reasonable for your current walker to be repaired.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment can in no case be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. In this case, the documentation states you have received four walkers in 3 years. Based on Medicare rules during the reasonable useful lifetime, it is reasonable to have your current walker repaired. Based on this information, we decided that Medicare rules for coverage of a replacement walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement walker.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the device is not indicated for the enrollee.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 4, 2021, to February 12, 2021.

You asked the Plan to pay for the services. You say that a valid diagnosis for this encounter was used. The Plan denied your request. The Plan says the DRG was updated in this case.

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 DRG 682 (RENAL FAILURE WITH 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found renal failure with MCC was reported and requested. Renal failure with CC is more appropriate. Metabolic encephalopathy was reported but based on the reports, symptoms of inability to speak or move resolved in the Emergency Department prior to admission when she did not have a neurological deficit, and would not meet criteria for this diagnosis. Therefore, renal failure with CC (DRG 683) is more appropriate in this case according to the provided records. 

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 inpatient hospital services provided to the enrollee from February 4, 2021, to February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on November 30, 2020 by the out of network dentist.

You asked the Plan to pay for the dental service. You say that this should be covered in full. The Plan denied your request. The Plan says since the provider is out of network, the plan pays according to a maximum allowable fee schedule. The Plan also says you are responsible for all fees in excess of this amount from the billed amount.

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 extraction is listed as covered, out of network dentist may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on November 30, 2020 by the out of network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary to maximize rehabilitation potential. The Plan denied your request. The Plan says this 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for bilateral subdural hematoma. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) 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 filling (D2391), crown (D2740), and unspecified preventive service (D1999) provided on June 15, 2021.

You asked the Plan to pay the in-network rate for the crown and unspecified preventive service. You say that you selected a dentist off of the in-network list before you had this work done. You say that you are now being told the dentist is not in network. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says crown is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered either.

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 crown and unspecified preventive service are not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay the in-network rate for the filling (D2391), crown (D2740), and unspecified preventive service (D1999) provided on June 15, 2021.