Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) HH skilled nursing services (CPT code G0299 X 4), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says records show that the enrollee had four (4) nursing visits previously approved to help the enrollee. The Plan state the enrollee's vital signs, taken by the home health nurse, are stable, and there have been no recent changes to the enrollee's treatment plan or their medications. The Plan states the enrollee's medical condition has not changed recently and the enrollee has caregivers available to help manage their treatment as needed. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.

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 the services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). Blood draws alone are not considered a skilled nursing need. As such, the requested, ongoing, HH registered nursing (RN) 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) HH skilled nursing services (CPT code G0299 X 4), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. The enrollee was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. There were no signs of opioid withdrawal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lift recliner purchased from a provider not contracted with Medicare on June 19, 2021.

You asked the Plan to pay for a lift recliner. You say that this equipment was necessary for your condition. The Plan denied your request. The Plan says payment is not available to a provider that does not participate with Medicare.

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 a lift recliner purchased from a provider not contracted with Medicare on June 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) and the home visit for the evaluation and management of a new patient (99343) rendered by the out-of-network (OON) provider on May 3, 2021 and May 5, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) and the home visit for the evaluation and management of a new patient (99343) rendered by the out-of-network (OON) provider on May 3, 2021 and May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for dental pain treatment (D9110) provided on May 6, 2021, and a denture addition (D5650) provided on May 11, 2021.

You asked the Plan to pay the full cost for dental pain treatment and a denture addition. You say that you were told you would not have to pay anything for dental services. The Plan denied your request. The Plan says these services 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. The Plan covers treatment of dental pain with a 50% coinsurance and denture repair with a 70% coinsurance. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the services covered under this benefit have cost-sharing that is your responsibility. You have been asked to pay a 50% coinsurance for dental pain treatment and a 70% coinsurance for a denture addition. This means that you have been charged the correct amount according to your dental benefit. Therefore, we decided that the Plan does not have to pay the full cost for dental pain treatment (D9110) provided on May 6, 2021, and a denture addition (D5650) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 25, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a skilled nursing setting POS 31.
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with the laboratory POS code while the record indicates that the member received their face-to-face service in a skilled nursing facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day.
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 a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve daily dialysis.

You asked the Plan to pre-approve daily dialysis. You say that the records provided support the need for the requested services. The Plan denied your request. The Plan says that daily dialysis is considered an experimental, investigational, and unproven treatment.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve daily dialysis. Our reviewer says that daily dialysis is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has end stage renal disease, is on hemodialysis, and is undergoing training for home hemodialysis. Home Hemodialysis is an accepted dialysis modality that has very good outcomes. It is not experimental therapy and is considered as a commonly accepted standard of practice that is widely utilized throughout the country and advocated by many. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of daily dialysis have been met. Therefore, we decided that the Plan has to pre-approve daily dialysis.

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 pre-approve a replacement Bi-Level Positive Airway Pressure (BiPAP) device.
You asked the Plan to pre-approve a replacement BiPAP device (E0471). You say that the enrollee's BiPAP is old and on a recall so the enrollee requires a new BiPAP. The Plan denied your request. The Plan says a new sleep study and prescription are required.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The original sleep study was done in 2014. The request is for a new BiPAP of a different brand which may require different settings. You have recommended a repeat Pap titration study. There is no physician order. Based on this information, we decided that Medicare rules for coverage of a replacement BiPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement Bi-Level Positive Airway Pressure (BiPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay
provided from April 1, 2021, to April 22, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were advised that you would
have no copayment. The Plan denied your request. The Plan says the copayment applied was correct.
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 $0
copayment per day for days 1-20, and a $100 per day for days 21-100 for Skilled Nursing Facility (SNF) care.
You have been asked to pay an $800 copayment for days 21-28 of your SNF visit ($100 x 8 days). A SNF visit
falls within the Skilled Nursing Facility (SNF) 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 a SNF stay provided from April 1, 2021, to April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 6, 2021, to April 7, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee received inpatient level of care to stabilize her condition and improve her symptoms until member was stable to discharge home. The Plan denied your request. The Plan says criteria was not met for inpatient admission.

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 at the time of admission, there was no expectation that the patient would require hospital services that would likely cross two midnights. Our physician reviewer found there were no high-risk features on the endoscopy and she was hemodynamically stable on admission. A lower level of care would have been more appropriate for continued 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 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 on April 6, 2021, to April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recement of crown (D2920) and palliative treatment of
dental plain (D9110) provided from April 21, 2021, to May 12, 2021.

You asked the Plan to pay for the dental services. You say that you do not understand why more of this claim
was not covered. The Plan denied your request. The Plan says recement crown is not listed as a covered
service. The Plan says that palliative treatment of dental pain is not listed as a covered service 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 dental services are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the recement of crown
(D2920) and palliative treatment of dental plain (D9110) provided from April 21, 2021, to May 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services provided to the enrollee on May 30, 2021, by an out-of-network provider.

You asked the Plan to pre-approve the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers.

The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services provided to the enrollee on May 30, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic x-ray (72190) provided on January 2, 2020.
You asked the Plan to pay for the pelvic x-ray. You say that you would like reconsideration because this service was not a duplicate or bundled. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the services were rendered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the pelvic x-ray was not filed until May 7, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the pelvic x-ray (72190) provided on January 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided on April 24, 2021, by an
OON provider.

You asked the Plan to pay for the outpatient clinic visit. You say that the enrollee had gone into preterm labor
and an authorization was not obtained. The Plan denied your request. The Plan says enrollees must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided on April 24,
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on April 13, 2021.
You asked the Plan to pay for the ambulance service. You say that you had fallen and could not get up. You say that you called an ambulance with your medical alert system. You say that you did not want to go to the hospital as it was not needed. You also say that you do not feel you should have to pay this bill. The Plan denied your request. The Plan says without ambulance transport, the claim is not payable per Medicare guidelines.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on April 13, 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 care is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the request does not meet requirements for approval.
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 that there is no documentation provided indicating medical necessity for the requested LTACH services. 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. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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 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 provided on October 14, 2020.