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

We decided that the Plan does not have to pay for the laboratory services coded 81408, 81230, 81291, 81335, 81225, 81226, 81240, 81241, 81227, 81355, 81400, 81231, 81232, 81256, 81283, 81328, 81350, and 81479 provided on May 17, 2021.  

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 payable.  

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 81408, 81230, 81291, 81335, 81225, 81226, 81240, 81241, 81227, 81355, 81400, 81231, 81232, 81256, 81283, 81328, 81350, and 81479 is not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel consists of a single procedural service, so one code must be submitted for the panel. Review of the file shows that more than one code was submitted for the services rendered. This means that  codes 81408, 81230, 81291, 81335, 81225, 81226, 81240, 81241, 81227, 81355, 81400, 81231, 81232, 81256, 81283, 81328, 81350, and 81479 are not separately payable.  

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 81408, 81230, 81291, 81335, 81225, 81226, 81240, 81241, 81227, 81355, 81400, 81231, 81232, 81256, 81283, 81328, 81350, and 81479 provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused evaluation, local anesthesia, complicated sutures, diagnostic casts, and re-evaluations provided from January 13, 2021 through May 18, 2021.

You asked the Plan to pay for the problem focused evaluation, local anesthesia, complicated sutures, diagnostic casts, and re-evaluations. You say that the dentist does not submit claims on behalf of patients so any benefits should be payable to you. The Plan denied your request. The Plan says the x-ray, extraction, surgical placement of implant, and IV sedation have been approved. The Plan also says that a problem focused evaluation, local anesthesia, complicated sutures, diagnostic casts and re-evaluation are not covered 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 pay for the problem focused evaluation, local anesthesia, complicated sutures, diagnostic casts, and re-evaluations provided from January 13, 2021 through May 18, 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 you have pneumonia and are not able to get out of bed. You say that you need physical therapy to gain strength. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The enrollee is ambulating household distances with contact guard assistance. She is near her prior level of function and can receive services at 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (bls-emergency) (A0429) provided August 6, 2021.  You asked the Plan to waive the copayment for the emergency ambulance transport. You say that you don't think you should have to pay for a second ambulance ride. The Plan denied your request. The Plan says the copayment has been 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 $225 copayment for each Medicare-covered ambulance service or one-way trip by ground transportation.  You have been asked to pay a $225 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (bls-emergency) (A0429) provided August 6, 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 you believe that you need inpatient rehabilitation. The Plan denied your request. The Plan says you do not meet the Medicare criteria for this level of care.  

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 enrollee was admitted to the hospital on 12/8/2021 with ischemia in the right leg. He required surgical treatment including a right below-the knee amputation on 12/13/21. He has been treated for pneumonia with antibiotics. He has improved clinically. He is non-weight bearing on the involved leg, and the documentation indicates there may be a need for further amputation due to non-healing of the incision.  

The requirements for admission to an inpatient rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per week (or at least 15 hours over a seven-consecutive day period). Additionally, an individual requires multiple types of therapies one of which should be physical or occupational therapy. In this case, there is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. He is unable to ambulate due to weight bearing restrictions and debility and can receive skilled services at 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve placement of the LINX reflux management system.  You asked the Plan to pre-approve the LINX procedure. You say that this is a medically necessary procedure. The Plan denied your request. The Plan says this procedure is not considered to be reasonable and necessary for the diagnosis or treatment of injury or disease.  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 pre-approve the LINX procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a normal BRAVO test, normal esophagram, no evidence of Barrett' esophagus or hiatal hernia. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   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 LINX procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the LINX reflux management system.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve ophthalmology services with an out-of-network provider.
You asked the Plan to pre-approve out-of-network ophthalmology services. You say that you are being referred to the out-of-network provider due to your current eye condition, but it is not being approved. You say that you were with this provider previously when you had another health insurance. The Plan denied your request. The Plan says that the requested service is available in-network.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not verified that there are doctor's in-network that can provide the necessary level of care. Of note, we requested this information without response. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve ophthalmology services with an out-of-network provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement prosthesis and prosthesis accessories.  You asked the Plan to pre-approve a replacement prosthesis and prosthesis accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that prostheses are only covered for certain indications. The rules also say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 a replacement prosthesis and prosthesis accessories. Our reviewer says that the documentation does not support that the requested prosthesis is medically reasonable or necessary. Our physician reviewer found you received a new lower extremity prosthesis in June 2021. The documentation does not support that you have a diagnosis/condition that meets criteria for the requested items. You have a new prosthesis supplied in June 2021; a replacement socket for your prior prosthesis is not eligible for coverage.  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 replacement prosthesis and prosthesis accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis and prosthesis accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the combination sit to stand frame/table system (E0637).

You asked the Plan to pre-approve the sit-to-stand frame/table system. You say that this is a medically necessary and you do not understand why this is denied ads not a medical necessity. The Plan denied your request. The Plan says this is a convenience item and not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the combination sit to stand frame/table system (E0637).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint nerve radiofrequency ablation (64635, 64636).  You asked the Plan to pre-approve facet joint nerve radiofrequency ablation. You say that this is medically necessary. The Plan denied your request. The Plan says this would exceed the frequency limitation for this service.  The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region, no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.  We looked at the file and Medicare rules. The records show that the enrollee has already had 2 radiofrequency sessions within the past 12 months. Based on this information, we decided that Medicare rules for coverage of facet joint nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint nerve radiofrequency ablation (64635, 64636).
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.  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 admission is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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: 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 enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 was admitted for metabolic encephalopathy. Medical problems are stable. There are no complex nursing or rehabilitation needs.   The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of the Reactiv8 Restorative Neurostimulation Device.  

You asked the Plan to pre-approve the Reactiv8 Restorative Neurostimulation Device. You say that this should be approved due to medical necessity. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.  

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 pre-approve the Reactiv8 Restorative Neurostimulation Device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested restorative neurostimulator is considered experimental at this time. More research is needed to show safety and efficacy.  

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 Reactiv8 Restorative Neurostimulation Device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of the Reactiv8 Restorative Neurostimulation Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on March 9, 2021 and crown provided on March 11, 2021.

You asked the Plan to pay for the limited oral evaluation and crown. You say that even if the dentist is out-of-network you would still have coverage. You say that you have dental coverage up to a max of $2,000 annually and the claim should be paid. The Plan denied your request. The Plan says payment cannot be issued for services provided by a dentist who has opted out of Medicare.

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, services provided by a dentist who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on March 9, 2021 and crown provided on March 11, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 was admitted for right knee pain after falling from a chair. Medical problems are stable. There are no complex nursing or rehabilitation needs.   The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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.