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

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the
requested IRF care 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre. You say that the enrollee is unable to adjust insulin due to their mentation. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested item is not medically necessary and there is no need for frequent adjustment of the enrollee's insulin regimen.
The Plan must follow 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 a Freestyle Libre. Our reviewer says that the requested item is medically necessary in this case. Our physician reviewer found that the blood glucose data gathered by the requested item will be called in to the provider so this data will help with insulin dose adjustments. The enrollee may not be able to do this on their own but, with the help of the treatment team, the data will be used. The enrollee is on multiple daily doses of insulin. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87651, 87798, 87641,
and 87500 provided on May 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes 87486, 87651, 87798, 87641, and 87500 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87651, 87798, 87641, and 87500 provided on May 12, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the
requested level of care 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient Telehealth visit (CPT code 90832) provided to the enrollee on March 18, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare payment for clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the state, with patient consent, and consult with the attending or primary care physician. There was no documentation of one or more of the criteria in the enrollee's Medicare MLN Booklet - MEDICARE MENTAL HEALTH -https //www.cms.gov/files/document/medicare-mental-health.pdF. Therefore, we decided that the Plan does not have to pay for outpatient Telehealth visit (CPT code 90832) provided to the enrollee on March 18, 2021, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on November 9, 2020.

You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be processed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral x-ray (D0220) and re-cementing or re-bonding of a crown (D2920) provided on May 12, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were told these are covered services and you chose this provider because you were unhappy with the previous in-network dental provider that you saw. The Plan denied your request. The Plan says out-of-network services are not covered by your dental benefit. There were other in-network providers who could have provided 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, items or services received from out-of-network providers are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0220) and re-cementing or re-bonding of a crown (D2920) provided on May 12, 2021, by an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital stay provided on April 11, 2021 to April 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the inpatient stay. You say that the enrollee met inpatient criteria prior to her scheduled surgery for preoperative clearance with dental service and concern for dyspnea. The Plan denied your request. The Plan says enrollee's 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 inpatient hospital stay provided on April 11, 2021 to April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external bleaching for home application, per arch; includes materials and fabrication of custom trays (D9975) provided June 7, 2021.

You asked the Plan to pre-approve the bleaching. You say that you were told you could use your dental allowance for any service. The Plan denied your request. The Plan says they reviewed the phone call logs and verified that you were not told that bleaching is a covered service. Dental cosmetic services are not covered under your 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 pre-approve external bleaching for home application, per arch; includes materials and fabrication of custom trays (D9975) provided June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity for the enrollee because the enrollee is not suited to go home at this time. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion therapy supplies provided from March 22, 2021, to March 28, 2021.

You asked the Plan to pay for Injection, milrinone lactate, 5 mg (J2260), Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) (A4221) and Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the physician order did not indicate the specific supplies for the billed date of service and the Expected Duration of Therapy is March 20, 2021, before the claim date.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order or proof of delivery for the supplies provided in this case.

The proof of delivery does not have a tracking number on it, or a list of items delivered. The drug on the claim is not listed on the physician order. The Expected Duration of Therapy is March 20, 2021, before the date of service, therefore medical necessity cannot be established. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for infusion therapy supplies provided from March 22, 2021, to March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
February 19, 2021 to February 23, 2021.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, an
appropriate G and Q code are missing from the claim for the billed dates of service. Therefore, we decided that
the Plan does not have to pay for the home health services provided to the enrollee from February 19, 2021 to
February 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 27, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $440 copayment for ambulance services. The enrollee has been asked to pay a $440 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vasopneumatic device therapy procedure and subcutaneous
injection provided on September 14, 2020.
You asked the Plan to pay for vasopneumatic device therapy procedure represented by codes G0283, 99211,
97112, 96372, and 97112, and subcutaneous injection represented by codes J3490, J3420, J3415, J3411, J1955,
and J2001. You say that the enrollee has numbness, tingling and pain in bilateral feet. The Plan denied your
request. The Plan says there is no mention of edema in chart notes and these procedures are considered
investigational and not eligible for coverage for the treatment or neuropathies or peripheral neuropathies caused
by underlying systemic diseases.
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 device is to reduce edema or lymphedema, treatment of
peripheral neuropathy with this device is not considered medically reasonable and necessary. Based on this
information, we decided that Medicare rules for coverage of vasopneumatic device therapy procedure and
subcutaneous injection have not been met. Therefore, we decided that the Plan does not have to pay for
vasopneumatic device therapy procedure and subcutaneous injection provided on September 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and (D0330) provided April 21, 2021.

You asked the Plan to pay for the tooth extraction and panoramic x-ray. You say that the services were necessary, and you were unable to find a network provider to perform them. The Plan denied your request. The Plan says the services were provided out-of-network and upon reviewing call logs found no calls regarding network dental providers 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. The Plan covers the tooth extraction and panoramic x-ray when the services are obtained from a provider in the Plan's dental vendor network. 

We looked at the file and Medicare rules. In this case services were obtained from outside of the Plan's dental vendor network. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction and panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and (D0330) provided April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a WATTS3D biopsy (88361, 88312, 88305, 88104) provided on January 8, 2021.

You asked the Plan to pay for a WATTS3D biopsy. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly because the enrollee was a registered outpatient.

The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatients or outpatients, the inpatient or outpatient hospital place of service (POS) code would be reported regardless of where the face-to-face service takes place. 

We looked at the file and Medicare rules. The services at issue were billed with the independent laboratory POS code 81, but the enrollee was a registered outpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of a WATTS3D biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a WATTS3D biopsy (88361, 88312, 88305, 88104) provided on January 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
April 29, 2021.
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you felt that
you had no alternative due to your cardiac history. The Plan denied your request. The Plan says ambulance
response and treatment with no transport is not a payable service.
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 29, 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 ambulance response and treatment, no transport
provided on April 29, 2021.