Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay the in network rate for the immediate upper denture (D5130), immediate lower denture (D5140), simple extractions (D7140 x 8), and surgical extractions (D7210 x 10) provided on July 9, 2021.  You asked the Plan to pay the in network rate for the dental services. You say that when the provider contacted the plan prior to your appointment, they were not advised they were out of network. You say that you feel these services should be paid at the in network rate. You also say that if you had known the provider was out of network, you would not have had the work done. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered. The Plan also says that you did not contact the plan prior to the date of service to verify provider eligibility.  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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the immediate upper denture (D5130), immediate lower denture (D5140), simple extractions (D7140 x 8), and surgical extractions (D7210 x 10) provided on July 9, 2021.
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 July 12, 2021.  You asked the Plan to pay for the ambulance service. You say that the Plan should pay this bill. The Plan denied your request. The Plan says Medicare does not cover ambulance services if there is no transport.  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 July 12, 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 July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) and inpatient hospital admission.  You asked the Plan to pre-approve the services. You say that this procedure is needed due to valve insufficiency.  The Plan denied your request. The Plan says because the requested procedure is not medically necessary, the related inpatient hospital admission is also not medically necessary.  The Plan must follow Medicare rules. The rules say that TAVR can be covered for an indication other than aortic stenosis when the patient is enrolled in a covered clinical study.  The requested procedure cannot be approved, as the enrollee does not have aortic stenosis, and is not enrolled in an approved clinical trial. As the requested procedure is not approved, the accompanying hospital admission is also not approved. 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 transcatheter aortic valve replacement (TAVR) and inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.  You asked the Plan to pre-approve the admission. You say that you require continued care at the inpatient level of care. The Plan denied your request. The Plan says the records show that behavior has improved, and you are no longer a threat to yourself or others.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, it is not expected that you will improve in a reasonable period of time for the dates in question, as you do not have suicidal or homicidal ideation noted. You denied any auditory or visual hallucinations. You were compliant with treatment, while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health plan's denial of continued inpatient psychiatric services is appropriate.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 3, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services provided by out-of-network providers are not covered except in emergent or urgent situations, or unless prior authorization has been 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 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 laboratory services provided to the enrollee on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the internal eye photography service you had at an ophthalmologist's office on August 5, 2021.  You asked the Plan to waive the copayment for the ophthalmology services. You say that you were sent to an incorrect location the day prior and had to pay a $20 copayment for that.  You stated that you were then sent to the correct location where you only saw a technician.  You said that you should not be responsible for a second copayment. 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 $20 copayment per visit for vision care services.    You have been asked to pay a $20 copayment per visit for the ophthalmology services. This is a per-visit copayment, and it applies each time you visit the office, regardless of the reason for the visit. 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 the internal eye photography service you had at an ophthalmologist's office on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided on August 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON dental services. You say that you did not know that your dentist was no longer in-network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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 dental services provided on August 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the oncology visit you had on June 30, 2021.  You asked the Plan to waive the copayment for the oncology visit. You say that you believe you met your maximum out-of-pocket amount for the year, so this copayment should be waived. The Plan denied your request. The Plan says you had not yet met your maximum out-of-pocket at the time this claim processed, so the copayment applied 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 $25 copayment for specialist visits.   You have been asked to pay a $25 copayment for the oncology visit. The Plan provided us with a detailed breakdown of all of the out-of-pocket costs you have had for the year.  According to this breakdown, you had not yet exceeded your out-of-pocket maximum for 2021 at the time of the oncology visit in question. 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 the oncology visit you had on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on May 17, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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.  The targeted genomic sequence analysis panel 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 targeted genomic sequence analysis panel provided on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Closed treatment of hip dislocation (27250) provided on February 24, 2021.  You asked the Plan to pay for code 27250. You say that the medical records support the billing of code 27250. The Plan denied your request. The Plan says the medical records do not support the billing of code 27250.  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, the CPT Code Manual definition of code 27250 is Closed treatment of hip dislocation, traumatic; without anesthesia.  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 code 27250. Our reviewer says that the medical records do not support the billing of code 27250. Our reviewer found the records do not show that closed reduction was performed on the date of service billed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 27250 have not been met. Therefore, we decided that the Plan does not have to pay for the Closed treatment of hip dislocation (27250) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve insertion or replacement of neurostimulator system for treatment of central sleep apnea.  You asked the Plan to pre-approve insertion or replacement of neurostimulator system for treatment of central sleep apnea. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.  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 insertion or replacement of neurostimulator system for treatment of central sleep apnea. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have central sleep apnea which is treated with Bilevel Positive Airway Pressure device (BiPAP) Adaptive Servo Ventilation (ASV). The documentation shows that you are still struggling and have nightly snoring and non-restorative sleep as well as ongoing excessive daytime sleepiness. You are failing current aggressive BiPAP ASV treatment and are a candidate for the Remede implant at this time which is recommended by your doctors. Therefore, this request will be considered medically necessary as it meets criteria based on the provided documentation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion or replacement of neurostimulator system for treatment of central sleep apnea have been met. Therefore, we decided that the Plan has to pre-approve insertion or replacement of neurostimulator system for treatment of central sleep apnea.   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 Accu-Chek Guide Glucose Meter, two hundred (200) lancet, and 200 test strips with five (5) refills.
You asked the Plan to pre-approve the items. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says they have reached out to your provider's office three (3) times to obtain medical records, but they did not receive any. The Plan states the medical director was not able to determine the medical necessity for you to use the non-formulary brand Accu-Chek Guide blood sugar monitor and supply, and the request is denied.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the items. Our physician reviewer found they are not told why you need this particular brand of strips and meter to monitor your blood glucose sugar (BGS); hence, there is no reason why this non preferred brand should be covered. If there is a reason why this brand is medically necessary, the information should be provided and the case re-reviewed. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Guide Glucose Meter, two hundred (200) lancet, and 200 test strips with five (5) refills.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, thorax; without contrast material (CPT code
71250).
You asked the Plan to pre-approve the CT scan. You say that you would like to obtain a chest CT as you
continue to have persistent rib pain since a prior rib fracture suffered in 2020. The Plan denied your request.
The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 the CT scan. Our physician reviewer
found the review indicates that you have history of chest wall trauma with resultant rib fracture 1.5 years ago.
You have persistent pain at the site. Chest x-ray (CXR) at time of injury showed prob rib fracture, but there is
no subsequent CXR recorded. There is no specific clinical rationale for the requested CT scan. X-ray is
adequate for evaluation of middle and distal 1/3 fractures. No advanced imaging of the abdomen or pelvis is
indicated when there is chest trauma and no physical examination or laboratory evidence of abdominal and/or
pelvic injury. The review has determined that the requested CT scan is not medically reasonable or 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 the CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve CT scan, thorax; without contrast material (CPT code 71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF care. The Plan states you can
continue in a different setting such as skilled nursing facility (SNF).
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 you are medically stable and do not meet Centers for Medicare & Medicaid Services
(CMS) coverage criteria for an IRF admission. With your current medical stability, and no other medical
complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3)
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic
medical conditions. You have no acute rehabilitation nursing needs. At the current functional level needing
contact guard assist (CGA) for mobility, you do not require intensive therapies, consisting of at least 3 hours of
therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission
is not medically necessary. Document does not support the necessity for admission to IRF. While you will
benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be
safely met in an alternate and low intensity setting such as in an SNF with therapies.
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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold packs therapy rendered on July 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97010 is not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 97010 (hot or cold packs therapy) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy rendered on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an arm fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.