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

 We decided that the Plan does not have to pay for the inpatient hospital services provided from May 19, 2018, to May 24, 2018.  You asked the Plan to pay for the inpatient services. You say that the provider has appropriately assigned the diagnosis. The Plan denied your request. The Plan says the records do not support the secondary diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis K56.2, defined as volvulus. 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 inpatient services. Our physician reviewer found that the enrollee was admitted to the acute hospital with nausea and vomiting. A diagnosis code of K56.2 (volvulus) was used as a secondary diagnosis for her hospitalization.  Based on the medical records provided the enrollee's condition during the hospitalization in question is more accurately described by K31.89 as records document the enrollee had a large hiatal hernia with a volvulus of the stomach and not a volvulus of the intestines.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from May 19, 2018, to May 24, 2018.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to waive the copayment for a screening for lung cancer with low dose computed tomography provided on June 22, 2021.  You asked the Plan to waive the copayment for a screening for lung cancer with low dose computed tomography. You say that you have not paid in the past because this is a preventative test. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there are no cost-sharing charges for a screening for lung cancer with low dose computed tomography.   The medical records show that you received a screening for lung cancer with low dose computed tomography on June 22, 2021. There are no indications that this benefit was exhausted. Therefore, you cannot be charged for this procedure.   The Plan says you must pay a $140.55 copayment for a screening for lung cancer with low dose computed tomography. Based on the Plan contract, however, you cannot be asked to pay for a screening for lung cancer with low dose computed tomography. Therefore, we decided that the Plan has to waive the copayment for a screening for lung cancer with low dose computed tomography provided on June 22, 2021.   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 the transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 29, 2021.

You asked the Plan to pay for the TEMPR device. You say that the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 29, 2021 was medically necessary. The Plan denied your request. The Plan says the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 29, 2021 was not medically necessary.

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 TEMPR device. Our reviewer says that the provided transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 29, 2021 was not medically necessary. Our physician reviewer found the enrollee has polyneuropathy. She received transcutaneous electrical modulation pain reprocessing (TEMPR) therapy, also known as Scrambler therapy. This procedure is considered experimental/investigational. Therefore, the request is deemed 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 TEMPR device have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) device provided on July 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health care.  You asked the Plan to pre-approve home health care. You say that this care is medically necessary. The Plan denied your request. The Plan says this service was not ordered by a Physician and Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary. The rules say that a doctor must certify the need for home health care services. These services were ordered by a nurse practitioner. Also, the records provided do not show you meet the criteria required for home health services. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 4Kscore testing provided on October 12, 2020.  You asked the Plan to pay for the testing services. You say that the test reduces biopsies in men. The Plan denied your request. The Plan says the lab test is not reasonable and necessary.  The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing is only covered under certain medical indications.   We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the indications for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the additional intraoral x-ray (D0230). We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and endodontic therapy (D3310). You asked the Plan to pay for the additional intraoral x-ray (D0230). You say that you are facing two major surgeries both of which require a long recovery. You say that you want an additional 60 days to appeal your claim. The Plan says that a limited exam is only covered once per plan year. The Plan also says that the additional intraoral x-ray (D0230) and endodontic therapy (D3310) are not covered benefits.

We decided that the Plan has to pay for the additional intraoral x-ray.

The Plan says that the x-ray is related to the root canal and therefore not covered. The Evidence of Coverage clearly says that unlimited intraoral x-rays are covered per plan year and does not limit an intraoral x-ray be related to a covered procedure. Therefore, we decided that the Plan has to pay for the additional intraoral x-ray.

We also decided that the Plan does not have to pay for the limited oral evaluation and endodontic therapy.

The Evidence of Coverage clearly says that a limited oral evaluation is only covered once per plan year. The Plan paid for the limited oral evaluation provided on May 24, 2021 prior to receiving this claim, which exhausted your benefit. Endodontic therapy is not listed as a covered benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and endodontic therapy.

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: 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 would benefit from and can tolerate an intensive interdisciplinary program of 3 hours therapy per day 5 days per week under the supervision of a physician. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.  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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95886, 95908, 95957) provided January 13, 2021.

You asked the Plan to pay for the neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 95886, 95908, & 95957 is not supported in the medical record. Specifically, the technical report does not include documentation of nerve conduction studies. There is a more appropriate code to report for pedicle screw testing. CPT 95957 would not be reported for real-time monitoring and therefore, would not be covered. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95886, 95908, 95957) provided January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).  You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have 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 Euflexxa. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
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 the enrollee does 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 3, 2021, and September 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for OON services. You say that you would not have been able to obtain services without a proper referral. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  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 services were referred by providers who are not network providers with the Plan. The Plan had network providers available who could have provided the lab 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 lab services provided on June 3, 2021, and September 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the total electric hospital bed (E0265) purchased July 10, 2021 from an out of network provider.  You asked the Plan to pay for the total electric hospital bed. You say that through no fault of your own you were left needing to pay for this bed out of your own pocket, although it is supposedly covered by your insurance. The Plan denied your request. The Plan says this item is not covered by Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital bed (E0265) purchased July 10, 2021 from an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the urgent care visit you had on June 8, 2021.  You asked the Plan to reduce the copayment for the urgent care visit. You say that this should be treated like your primary care doctor's office and the copayment should only be $5. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for urgent care services.         You have been asked to pay a $40 copayment for the urgent care visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the urgent care visit you had on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on December 18, 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.t been met."]  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when specific criteria are met.  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 the services were not medically necessary. Our physician reviewer found the submitted documentation does not support that all of the criteria for coverage are met. It has not been demonstrated that the testing is to be used as an adjunctive personalized medical decision-making tool, and that the treating clinician has narrowed treatment possibilities to specific medications under consideration for use, or is already using a specified medication, based on other clinical considerations including the enrollee's diagnosis, the enrollee's other medical conditions, other medications, professional judgment, clinical science and basic science pertinent to the drug, and the enrollee's preferences and values. The testing was therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more toward the extraction and lower partial denture provided on August 12, 2021.  You asked the Plan to pay more toward the extraction and lower partial denture. The Plan denied your request. The Plan says the calendar year maximum has been reached.  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, you also have a maximum benefit of $1,000 toward covered dental services every year. The plan paid $310 toward the lower partial denture provided on August 12, 2021 to meet your $1,000 maximum, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more toward the extraction and lower partial denture provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair for resin Partial Denture Base, Maxillary (D5612) dental services for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are necessary for the enrollee. The Plan denied your request. The Plan says these services are not covered by the enrollee's dental benefit.

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 more than Medicare coverage, the requested repairs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve repair for resin Partial Denture Base, Maxillary (D5612) dental services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.

You asked the Plan to pre-approve services with an out of network provider. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck you had on September 14, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you don't know if you owe this amount because you initially paid this, but then your payment was sent back. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for ultrasounds.   You have been asked to pay a $60 copayment for the ultrasound. 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 ultrasound of the head and neck you had on September 14, 2021.