Persius/hicric huggingface dataset:
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee continues to receive acute care services, and these have not been
denied. The medical record does not indicate that the enrollee requires services that he is not currently
receiving but that would be available at the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) provided October 20, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you were unaware of the frequency
limit. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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. The Plan covers the
comprehensive oral exam once every three plan years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
exam was previously covered on July 19, 2021. Based on this information, we decided that the Plan's frequency
limit for coverage of the comprehensive oral exam has been exceeded.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or
established patient (D0150) provided October 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0427, A0425) provided on February 18, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were not informed
prior to services that you would owe this amount, and you did not call the ambulance yourself. The Plan denied
your request. The Plan says this claim was processed correctly, and your copayment was assessed in
accordance with your 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). Your contract with the Plan clearly says that you must pay a $200
copayment for each one-way ground ambulance trip.
You have been asked to pay a $200 copayment for the ambulance services. 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 transportation services (A0427, A0425) provided on February 18,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a root canal (D3348) provided by an out-of-network provider on September 13, 2021.
You asked the Plan to pay for the retreatment of a root canal. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental service is not a covered 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 in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Services must be provided by an in-network provider. Therefore, we decided that the Plan does not have to pay for the retreatment of a root canal (D3348) provided by an out-of-network provider on September 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toviaz.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Toviaz.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided June 20, 2021 to June 30,
2021.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically
necessary, and if the readmission did not result from a premature discharge from the same hospital.
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 reviewer says that
the documentation does not support that the readmission was medically reasonable or necessary. Our physician
reviewer found the enrollee was discharged from the hospital after treatment for worsening leg symptoms and
possible cellulitis following irregular treatment for chronic wounds in legs over prior months one visit to the
emergency department where the enrollee left against medical advice. The enrollee had been treated with
multiple courses of antibiotics from emergency department and outpatient visits for wounds. Wound culture
positive but thought to be possible colonizer and not infection source. The enrollee was treated with IV
antibiotics and wound care. Four days later, the enrollee's wounds were looking better. The enrollee wished to
be discharged to reduce risk of infection in the hospital due to immunocompromised state. The enrollee was
hemodynamically stable and without signs of severe infection. Lower level of care more appropriate for
chronic wound management. Therefore, the enrollee did not meet criteria for the services rendered.
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 inpatient services have not been met. Therefore, we decided that the Plan
does not have to pay for the inpatient services provided June 20, 2021 to June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ablation procedure (22899).
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Intracept procedure is still considered investigational. 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve an ablation procedure (22899).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 11, 2020.
You asked the Plan to pay for the laboratory services. You say that the services are payable for the emergency
room services rendered prior to the enrollee's hospice election. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper
billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The hospice
benefit is effective the date of election and is not time specific. Therefore, we decided that the Plan does not
have to pay for the laboratory services provided on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ablation procedure (22899).
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the requested Intracept procedure is experimental for back pain. 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve an ablation procedure (22899).
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 is not medically
necessary.
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 you do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation.
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 pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on July 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose
monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
You asked the Plan to pre-approve the sensors and transmitter. You say that this is medically necessary for you.
The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the
DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies
used with a non-therapeutic CGM.
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and
supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial
continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose
monitoring (A9277).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on June 10, 2021.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.
Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on June 10, 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 requested admission to an IRF is not medically
necessary.
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 you do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. Your care needs can be met 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a metabolic panel (80053) provided on August 31, 2021.  You asked the Plan to pay for a metabolic panel. You say that one unit should be paid. The Plan denied your request. The Plan says sufficient documentation has not been submitted.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We find that CPT code 80053 is not supported in the medical record. Specifically, no records documenting this service have been submitted. Based on this information, we decided that Medicare rules for coverage of a metabolic panel have not been met. Therefore, we decided that the Plan does not have to pay for a metabolic panel (80053) provided on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of January 29,
2022.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee is still a high risk to
herself and others. The Plan denied your request. The Plan says the denial of authorization for continued
inpatient psychiatric level of care is correct, because the enrollee is no longer a threat to self or others and is
awaiting placement at a lower level of care.
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. Our reviewer
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our
physician reviewer found it is not expected that the enrollee would improve in a reasonable period of time
beyond January 28, 2022, as she does not have suicidal or homicidal ideation noted and denied any auditory or
visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety.
It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient
level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care as of January 29, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that the enrollee was admitted with sepsis from pelvic abscess requiring operative
intervention.
The record indicates that the enrollee is improving but still requires acute care services, including thoracentesis
for pleural effusion. The enrollee continues to receive acute care services, and these have not been denied. The
medical record does not indicate that the enrollee requires services that he is not currently receiving but that
would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided from July 28, 2021, to August 18, 2021.
You asked the Plan to waive the copayments for debridement. You say that you should only owe a specialist copayment and disagree with the higher 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received debridement on July 28, 2021. Therefore, you are responsible to pay the allowed amount of $131.31, which is less than the $250 copayment. You received debridement on August 4, 2021. Therefore, you are responsible to pay the allowed amount of $131.31, which is less than the $250 copayment.
You received debridement on August 18, 2021. Therefore, you are responsible to pay the allowed amount of $68.17, which is less than the $250 copayment. The total amount you owe is: $330.79. You have been asked to pay the total copayment amount of $330.79 for debridement. Debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for debridement provided from July 28, 2021, to August 18, 2021.