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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's chance to return home and maintain 
living at home will be significantly reduced if his opportunity to participating in an acute rehab unit. The Plan 
denied your request. The Plan says these services can be provided in a less intense setting. 

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found Based upon the enrollee's current level of function does not require an intensive, 
complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy 
and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and low intensity setting 
such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 14, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction
is not a covered benefit for a medical vision check (age-related nuclear cataract, bilateral).
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered
diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicarecovered
eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided
that the Plan does not have to pay for an eye refraction provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on June 8,
2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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.
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. Cardiovascular risk assessment panels are only
covered for certain indications.
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the
cardiovascular risk assessment panel provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for a lumbar laminectomy surgery.
You asked the Plan to pre-approve bone marrow aspirate. You say that you are in a lot of pain and cannot walk any distance without pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that bone marrow aspirate is helpful for your condition.
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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is needed to show safety and efficacy when it is used as bone graft material.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for a lumbar laminectomy surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from February 21, 2021, to March 3, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in one hospital on February 21, 2021 and paid your cost sharing. After your surgery, you were transferred to a different hospital and had to pay a copayment again. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $490 copayment for days 1-3, and a $0 copayment for each additional day after you meet your $395 deductible for inpatient hospital care. You have been asked to pay a $490 copayment for days 1-3 for the inpatient hospital services, for a total of
$1470. The contract explicitly states that you pay this copayment each time you are admitted to a hospital, even
if you are transferred to a different facility. You had two separate admissions, so two copayments apply. 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 inpatient hospital services you received from February 21,
2021, to March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires and additional supplies provided on March 4,
2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate
payment is made.
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 looked at the file and the rules. We find that CPT codes A4557 and 99072 are bundled codes. When these
services are covered, payment for them is subsumed by the payment for the services to which they are incident.
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to pay for the lead wires and additional supplies provided on March 4,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 27, 2020.
You asked the Plan to pay for the services provided. You say that samples are sent from clinics and providers. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. We find that the claim lists a place of service as an independent laboratory. The records provided do not indicate the specimen at issue was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 27, 2020.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH which the enrollee requires that are not available at the health care setting being offered by the Plan. 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 pay for an interstitial continuous glucose monitor and supplies (A9276, A9277, A9278) provided on January 14, 2021.
You asked the Plan to pay for an interstitial continuous glucose monitor and supplies. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interstitial continuous glucose monitor and supplies have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for an interstitial continuous glucose monitor and supplies (A9276, A9277, A9278) provided on January 14, 2021.
Appeal type: Transportation
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 September 25, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee had 2 different transports on the same day. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer found that the documentation
did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on September 25, 2020. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on September 25, 2020. The reviewer also found that the documentation did not support that the ambulance transport on September 25, 2020, was medically reasonable and necessary for 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 ambulance services have not been met. Specifically, the file shows that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from October 12, 2019, to October 15, 2019, and billed with DRG (diagnosis related group) 314.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the primary diagnosis I27.23.
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 314, other circulatory system diagnoses with major complications or comorbidities, and a primary diagnosis of I27.23, pulmonary hypertension due to lung diseases and hypoxia. 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 inpatient care. Our reviewer says that the records do not support the billed DRG. Our physician reviewer found the discharge diagnosis given was chronic pulmonary hypertension. During this admission pulmonary hypertension was treated with oral sildenafil; acute diastolic congestive heart failure and chronic obstructive pulmonary disease (COPD) exacerbation were treated with intravenous Bumex, intravenous steroids and albuterol sulphate. Cardiology consult was performed with strict intake and output ordered and monitoring of kidney functions due to diuretics. Heparin was ordered; however, there is no documentation in the medical record that indicated this was for treatment of pulmonary hypertension. Oxygen therapy was increased for treatment of the acute respiratory failure, acute heart failure, exacerbation of chronic obstructive pulmonary disease, and pulmonary hypertension. Last, elevated blood pressures were not attributed to pulmonary hypertension. The physician indicated in the medical record the blood pressures were fairly and reasonably well controlled. 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 care provided from October 12, 2019, to October 15, 2019, and billed with DRG (diagnosis related group) 314.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the precision attachments (D5862 x 3), and surgical placement of mini implants (D6013 x 3) provided on February 25, 2021.
You asked the Plan to pay for the prevision attachments and surgical placement of mini implants. You say that the implants should be covered because they are related to your dentures. You also say that the dentures are listed as covered services. The Plan denied your request. The Plan says precision attachments are not listed as covered services. The Plan says that surgical placement of mini implants are not listed as covered services 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 prevision attachments and surgical placement of mini implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the precision attachments (D5862 x 3), and surgical placement of mini implants (D6013 x 3) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on April 26, 2021.
You asked the Plan to pay for the consultation. You say that you believe this service should be covered because it was medically necessary. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on May 25, 2021.
You asked the Plan to pay for a 2D oral/facial photographic image. You say that there was no payment on this claim. You also say that you went to one provider and was told a deep cleaning would cost about $1200. You went for a second opinion and was told it was going to be $199. You feel this should be covered and you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says there is no coverage for oral/facial photographic images obtained intra-orally or extra-orally. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and limitations.
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 a 2D oral/facial photographic image (D0350) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and testing to be provided by an out-of-area provider.
You asked the Plan to pre-approve the requested services. You say that you receive Avastin injections every 8 weeks. The Plan denied your request. The Plan says criterion has not been met for this request.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.
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 requested services. Our physician reviewer found that in this case, the record indicates you have age related macular degeneration. The record indicates that you are vacationing out of network for the next several months. The record does not provide sufficient medical records to determine the emergent or urgent nature of the requested services. Therefore, the requested services are not medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation and testing to be provided by an out-of-area provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexes therapy and multivitamin injections (97032, 
97112, J3490 and J7999) provided on January 5, 2021. 
 
You asked the Plan to pay for the Sanexas therapy and multivitamin injections. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not a 
Medicare covered service with the available information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sanexas therapy and multivitamin injections have not been met. Specifically, review of the file 
and publicly available records, we find that the physical therapy services at issue in this case were rendered by 
an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Additionally, the record 
does not contain documentation of the dosage and type of drug administered in each injection, which is 
required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to 
pay for the Sanexes therapy and multivitamin injections (97032, 97112, J3490 and J7999) provided on January 
5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603), two additional intraoral periapical x-rays (D0230 x2), and bitewing x-rays (D0274) provided on May 14, 2021.
You asked the Plan to pay for the caries risk assessment and documentation, additional intraoral periapical x-rays, and bitewing x-rays. You say that you believe you are being double billed for the x-rays, using different codes for the same exact work. The Plan denied your request. The Plan says the caries risk assessment and documentation is not covered under your benefit plan. The Plan also says that the intraoral periapical x-rays and bitewing x-rays are allowed twice per calendar year, and you have reached the limit for these services.
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, caries risk assessment and documentation (D0603) is not among those covered under this benefit. The contract says that intraoral x-rays and bitewing x-rays are limited to two of the following procedure codes per 1 calendar year: D0220, D0230, D0270, D0272, D0273, or D0274. The record shows that you received a first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) on May 14, 2021 which was covered by the Plan and your intraoral and bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603), two additional intraoral periapical x-rays (D0230 x2), and bitewing x-rays (D0274) provided on May 14, 2021.