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

We decided that the Plan does not have to pay for acupuncture provided on May 10, 2021, and May 24, 2021.
You asked the Plan to pay for acupuncture. You say that you have always been reimbursed for treatments with
this provider for several years. The Plan denied your request. The Plan says the diagnosis submitted on the
claim does not indicate chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, there are no records supporting chronic low back
pain. Therefore, we decided that the Plan does not have to pay for acupuncture provided on May 10, 2021, and
May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120), complete series of x-rays
(D0210), and dental cleaning (D1110) provided on April 29, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you believed you were covered in full for both
in-network and out-of-network dental care, and you did not understand that you would be responsible for this
cost or know that this provider was out-of-network until you received this bill. The Plan denied your request.
The Plan says these services were received out of network and were processed correctly according to your
contract. 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. For services obtained out-ofnetwork,
the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you may be
billed charges above what the Plan pays, even for services listed as a $0 copayment.
You chose to see an out-of-network provider on April 29, 2021. The provider billed a total of $325 for the
cleaning, exam, and x-rays. The Plan's total allowed amount for these services is $131. The Plan paid the full
$131 allowed amount for these services, because each of these is listed as having a $0 copayment in the Plan's
contract. This is the amount that an in-network provider would accept as full payment for this care; however,
out-of-network providers do not have this agreement and are allowed to bill you the difference between what
the Plan pays and the total amount billed. You have been asked to pay $194 ($325 - $131 = $194) for the
services at issue. This means you have been asked to pay the correct amount based on your contract with the
Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the periodic oral
exam (D0120), complete series of x-rays (D0210), and dental cleaning (D1110) provided on April 29, 2021, by
an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay for a right reverse total shoulder replacement for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of this admission was appropriate given the clinical scenario.
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 the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the requested total shoulder arthroplasty is documented to have been supported. However, detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for inpatient stay for right reverse total shoulder replacement 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay for a right reverse total shoulder replacement for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76857) provided May 14, 2021. You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and cannot be separately paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76857 has a bundled relationship with code 76775 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76857) provided May 14, 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you remain fully ventilator dependent and critically ill. You continue to receive acute care services, and these have not been denied. The medical records do not indicate that you require services that you cannot currently receive but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom-made orthotics (shoe inserts).
You asked the Plan to pre-approve foot orthotics. You say that it is very hard to do daily activities due to constant heel pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom-made orthotics (shoe inserts).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from August 1, 2020 to August 16, 2020.
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 the services were 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications in the SNF and had stable vital signs. He was treated for a urinary tract infection. He received physical, occupational, and speech therapy and needed assistance with functional mobility and activities of daily living. He worked with speech therapy on cognitive linguistic deficits. He had no skilled nursing or skilled therapy needs. He did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from August 1, 2020 to August 16, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility patient coded as 99380 provided on March 29, 2021.

You asked the Plan to pay for the supervision of a nursing facility patient. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment for this service is paid under Medicare.

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 code 99380 is not eligible for payment. Specifically, this code has a status code of "B" for bundled code under the Physician Fee Schedule. Payment for services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility patient have not been met.

Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility patient coded as 99380 provided on March 29, 2021.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Ilumya. Our reviewer says that the medication is necessary. Our physician reviewer found the documentation supports that the administration of the plan's required drugs would potentially place the enrollee in this case at greater risk of adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have been met. Therefore, we decided that the Plan has to pre-approve Ilumya.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 9, 2020, to July 13, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting payment for the medically necessary services. The Plan denied your request. The Plan says that the care provided was post-stabilization care, not urgent or emergent care, with no prior authorization.
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 the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was evaluated and admitted with abdominal pain. The enrollees condition stabilized and improved, and the enrollee was discharged home when considered medically stable. The records showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 9, 2020, to July 13, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 13,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on
April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical
stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each
additional 15 minutes (97811) infrared light therapy (97026) provided February 5, 2021.
You asked the Plan to pay for the acupuncture services. You say that according to the enrollee's benefit
verification, this is a covered benefit under the health Plan. Please review the enclosed documentation and
allow for coverage as the services rendered were medically necessary. The Plan denied your request. The Plan
says the Plan does not cover this expense and does not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the records show that the treatment was for right
shoulder and neck pain. Infrared therapy is considered not reasonable and necessary by Medicare and is
excluded from coverage. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more
needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without
electrical stimulation, each additional 15 minutes (97811) infrared light therapy (97026) provided February 5,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) for date of service April 28, 2021.

You asked the Plan to pay for the chiropractic services. You say that at your age your doctor's will not give you any pain medication or muscle relaxers. You have to rely on chiropractic methods to get some relief. You see no reason why this should be denied. The Plan denied your request. The Plan says the medical record does not document a diagnosis of subluxation of the spine.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

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 chiropractic services Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the enrollee received manual manipulation of the spine to correct a subluxation. 

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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) for date of service April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $40 copayment for specialist on June 27, 2021.

You asked the Plan to waive this copayment. You say that you did not ask this physician to come in your room. The Plan denied your request. The Plan says according to the Plan this copayment was 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 $40 copayment for specialist services. 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 $40 copayment for specialist services provided on June 27, 2021.