Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the emergency room services provided on September 8, 2021.  You asked the Plan to waive the copay for the services provided. You say that you were told you would have no copays because you were on Medicaid. The Plan denied your request. The Plan says the copay 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 $90 copay for emergency care.     You have been asked to pay a $90 copay for the services provided. The services fall within the emergency 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 copay for the emergency room services provided on September 8, 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 the enrollee requires inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee does not have complex rehabilitation needs and can receive the necessary skilled therapies in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met in a lower 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic testing provided on June 17, 2021.  You asked the Plan to pay for diagnostic testing. The Plan denied your request. The Plan says the Plan includes this charge in the facility benefit. You should bill the facility.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage of the diagnostic testing have not been met. Specifically, this claim was billed with the mobile unit place or service code while the records indicate that the mobile unit was serving a facility for which a place of service code already exists. Additionally, payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for diagnostic testing provided on June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 30, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from December 30, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  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 care from December 30, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 30, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond December 30, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 care from December 30, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 30, 2021, forward.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. It is not safe or necessary to transfer the enrollee at this time. The enrollee may continue ongoing active treatment at the current inpatient facility.  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 record indicates that the enrollee still requires supplemental oxygen and has encephalopathy requiring acute care services. The enrollee is receiving ongoing acute care services at the current facility, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the outpatient services provided from August 11, 2021, to September 20, 2021.  You asked the Plan to reimburse you for the outpatient services. You say that you were unsuccessful at find an in network doctor that was available. You say that you should be reimbursed at the rate of an in network dentist The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the outpatient services provided from August 11, 2021, to September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical assistant services provided at a percutaneous implantation of neurostimulator electrodes (63650) on June 10, 2021.  You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because surgical assistant services are not covered for the procedure at issue.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 63650. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided at a percutaneous implantation of neurostimulator electrodes (63650) on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11720, 11721) rendered by the out-of-network (OON) provider on September 1, 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 nail debridement (11720, 11721) rendered by the out-of-network (OON)
provider on September 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient (CPT code 90832) provided to the enrollee on June 2, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 service have not been met. Evaluation and management by psychologists is covered by Medicare under the following conditions: *Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. If consultation with the attending or primary care physician is unsuccessful, document in the patient's medical chart with the date and manner of notification to the physician does not consent If attempts to consult directly with the physician are not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the beneficiary. There was no documented contact with the attending/primary care physician. The listing of a referring provider on the claim does not satisfy the documentation criteria. There is no referring physician listed on the claim. Therefore, we decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient (CPT code 90832) provided to the enrollee on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Clinimix infusion provided on June 30, 2021.  You asked the Plan to pay for a Clinimix infusion. You say that this is supported in the records. The Plan denied your request. The Plan says this is experimental.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a Clinimix infusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested infusion.  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 Clinimix infusion have not been met. Therefore, we decided that the Plan does not have to pay for a Clinimix infusion provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested wheelchair exceeds the enrollee's medical needs. The documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer, or  utilizes intermittent catheterization for bladder management, or needs a power seating system to  manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). There is no need for a special drive control. The enrollee's strength and functional ability with independence in eating  should be sufficient to control any power options through their own switches.  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 a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a biopsy of skin lesion provided on August 25, 2021, by an out-of-network provider.  You asked the Plan to pay for a biopsy of skin lesion. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 a biopsy of skin lesion provided on August 25, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. 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 she 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2), comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on September 16, 2021  You asked the Plan to pay for the scalings and planings, comprehensive oral evaluation, and intraoral periapical x-rays. You say that your teeth were not cleaned. You also say that you do not feel you should be held responsible for this bill. The Plan denied your request. The Plan says the periodontal scalings and root planings are not a covered expense under your dental plan. The Plan also says that your benefits for the comprehensive oral evaluation and intraoral periapical x-rays have been satisfied and the frequency limitations have been exceeded.  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, periodontal scaling and root planing (D4342) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure code every three years, and that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a comprehensive oral evaluation (D0150) and first intraoral periapical x-ray (D0220) on August 27, 2021 and your comprehensive oral evaluation (D0150) and intraoral x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2), comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on September 16, 2021
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs may be met at a lower level of care.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a genicular nerve block provided to the enrollee on June 24, 2021.  You asked the Plan to pay for the block. You say that this request is consistent with patient protocol, and clearly falls under the scope of practice with the state. The Plan denied your request. The Plan says experimental or investigational services are not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this was an experimental/investigational treatment. Therefore, the procedure was 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 block have not been met. Therefore, we decided that the Plan does not have to pay for a genicular nerve block provided to the enrollee on June 24, 2021.