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

We decided that the Plan does not have to pay for the blood smear coded 85060 provided on May 10, 2021.
You asked the Plan to pay for the blood smear. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are not payable as billed.
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, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by
physician with written report.
We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a Professional
Component (PC)/Technical Component (PC/TC) indicator of 8 per the Physician Fee Schedule Search. Code
85060 may not be paid if furnished to hospital outpatients or non-hospital enrollees. Review of the file shows
that this code was billed with place of service 11 (outpatient hospital). Based on this information, we decided
that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan
does not have to pay for the blood smear coded 85060 provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 12, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you never went to the office visit and did not received any services. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for services obtained by a specialist. 

The medical records show that you had a specialist visit on July 12, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 19, 2020.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says the benefit is limited to the Plan's hearing aid vendor's advanced and premium hearing aids, which come in various styles and colors. You must see the Plan's hearing aid vendor provider to use this benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only benefit is limited to the Plan's hearing aid vendor's advanced and premium hearing aids, which come in various styles and colors. You must see the Plan's hearing aid vendor provider to use this benefit. We looked at this physician's review, the file, and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 20, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you waited five hours for the ambulance and should not be responsible for the charges. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $365 copayment for ambulance services. 

You have been asked to pay a $365 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical decompression.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says you do not have a healthy weight for your height.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy of this procedure. High failure rates have been reported.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical decompression.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional attendant care services (S5125).
You asked the Plan to pre-approve the attendant care services. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says you do not meet the criteria for attendant care services.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the attendant care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. The record shows that you specifically state that your wound is completely healed, and you can perform most daily activities on your own. Therefore, we decided that the Plan does not have to pre-approve additional attendant care services (S5125).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on April 26, 2021 and May 10, 2021.

You asked the Plan to pay for these services. You say that you were unaware prior authorization was needed.
The Plan denied your request. The Plan says the services are not covered.

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.

The records show that the service at issue is not manual manipulation of the spine. The file shows that the
provider submitted claims for procedure codes 99211 (office visit) and 72125 (computed tomography scan of
the cervical spine). These services are not covered when billed by a chiropractor. Billed procedure code 98940
(manual manipulation) is not covered because there is no documentation to support that you had a subluxation
of the spine as defined by Medicare. Therefore, we decided that the Plan does not have to pay for the services
rendered on April 26, 2021 and May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on March 19, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does not meet the requirements for the claim to be paid.

The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the enrollee. 

We find that the testing at issue is not supported in the medical record. Specifically, the medical records do not indicate the results of the testing would be used in the management of the enrollee's specific medical problem. The records do not clearly document the physician's intent that the testing to be performed. 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 hereditary cardiovascular gene panel provided on March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on June 16, 2021, to June 18, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that that these services were appropriate based on the past medical history, advanced age, high risk and complex medical history and multi dose schedule. The Plan denied your request. The Plan says that this stay was not medically necessary because the records show the enrollee had not received this chemotherapy before and had no complications from the chemotherapy administration.
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 tolerated the chemotherapy and was discharged home when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 on June 16, 2021, to June 18, 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: 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 appropriate care at the present acute care hospital. 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. 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 pre-approve office visits and therapy services to be provided by a chiropractor.

You asked the Plan to pre-approve office visits and therapy services. You say that your body is out of alignment and in pain, so you want to see a chiropractor to relieve your pain and avoid medication. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.

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. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve office visits and therapy services to be provided by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 6, 2021, to February 26, 2021.

You asked the Plan to pay for chiropractic services. You say that the provider did not want to submit these claims and submitted them incorrectly. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were not medically necessary or not covered.

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. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the Plan sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Neither the provider nor you have submitted medical records to the Plan for review. The Plan contact the provider and requested medical records, but the provider advised that they would not send medical records to the Plan. Without records, we cannot determine whether the chiropractic services performed were medically necessary and meet Medicare and Plan rules for coverage. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from January 6, 2021, to February 26, 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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care
needs can be met 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 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. 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 this
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: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the $10.44 coinsurance for a commode provided on February 6, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was applied based on the Plan contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says enrollees must pay 20% coinsurance for durable medical equipment. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling with the Plan. Therefore, we decided that the Plan does not have to waive the $10.44 coinsurance for a commode provided on February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (64642, J0858, 76942).

You asked the Plan to pre-approve Botox injections. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for you condition.

The Plan must follow Medicare rules. Medicare rules say that the patient's medical record should include a covered diagnosis as listed in the Local Coverage Article to support the medical necessity of the Botulinum Toxin injection. 

We looked at the file and Medicare rules. The diagnoses listed in the submitted medical records, M79.2, neuralgia and neuritis, unspecified, and M79.671, pain in right foot, are not listed as covered diagnoses for Botox injections. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (64642, J0858, 76942).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 11, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were not aware that you would also owe a $30 office copayment. You also state that the records are wrong and that the physician did not examine you. The Plan denied your request. The Plan says the claims were processed correctly and are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist services. The medical records show that you had a specialist visit on June 11, 2021. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on June 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 27, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the ambulance benefit is for transport only. If there is no transport, it is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 27, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement oxygen equipment.
You asked the Plan to pre-approve these services. You say that the enrollee cannot easily transport her oxygen
tanks to visit family. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve replacement oxygen equipment.
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 a transfer to a LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee should remain at the current level of care since she felt she may not be able to make a reasonable recovery.
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 appears to be stabilizing but is not a candidate for weaning and requires additional short-term acute care services that can be safely completed at the current acute care facility. The enrollee does not require services at the LTACH that are not already available at the current 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.