Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the panoramic x-ray (D0330) provided on May 20, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you do not agree with the amount that was reimbursed to you when your dental benefit is unlimited. The Plan denied your request. The Plan says 1 complete series or panoramic x-ray is covered every 36 months. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and panoramic x-ray is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for the complete series x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the panoramic x-ray (D0330) provided on May 20, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transportation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON ambulance transportation. You say that the enrollee needs to be transported from her nursing home to dialysis. The Plan denied your request. The Plan says there is a network transportation vendor who can provide non-emergency ambulance transportation for this enrollee. There is no need documented that the OON provider requested is medically necessary.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided March 31, 2021, and April 12, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the bills are too high, and you cannot afford them. The Plan denied your request. The Plan says the copayments were 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 $300 copayment for Medicare-covered ambulance transport (one-way). You have been asked to pay a $300 copayment for the ambulance service on April 12, 2021. You have been asked to pay a $278.41 copayment for the ambulance service on March 31, 2021, since the total cost of the
service was less than the required copayment. The 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided March 31, 2021, and April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested inpatient care is not medically reasonable and necessary in this case.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found that the enrollee is medically stable and has been provided medical clearance to undergo a shoulder arthroplasty, an elective procedure. The planned procedure listed under CPT code 23472 is not listed on the Medicare Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The review has determined that the record does not show that at the time of inpatient admission the admitting physician would reasonably expect that the enrollee's necessary hospital care will 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation
services (A0427, A0425) and the air ambulance transportation services (A0430, A0435, A0434, A0425)
provided on March 15, 2021, and March 16, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel these services
were only necessary because your surgery went wrong, and you should not be responsible for these additional
costs. The Plan denied your request. The Plan says these claims were processed correctly, and your cost sharing
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 $250
copayment for each one-way Medicare covered ground trip and a $250 copayment for each one-way Medicare
covered air trip.
You have been asked to pay a $250 copayment for each of the ground or air ambulance trips. 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 emergency ambulance transportation services (A0427, A0425)
and the air ambulance transportation services (A0430, A0435, A0434, A0425) provided on March 15, 2021,
and March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from September 27, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the services have enabled great progress from where the enrollee started and they need continued work with the successful therapy they are providing. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from September 27, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 12, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services 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. 

We find that CPT code 80307 and HCPCS G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days for SNF care.
You asked the Plan to pre-approve SNF care. You say that the additional SNF days are medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from June 16, 2021, through October 7, 2021. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve additional days for SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test.
You asked the Plan to pre-approve an OmniSeq Insight Panel test. You say that the documentation provided supports the need for the requested testing. The Plan denied your request. The Plan says the clinical information does not support that the requested test is 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 pre-approve an OmniSeq Insight Panel test. Our
reviewer says that an OmniSeq Insight Panel test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has recurrent squamous cell carcinoma of the lung. The enrollee was previously treated with surgery and neoadjuvant chemotherapy in combination with immune therapy. On September 9, 2021, the plan was for chemoimmunotherapy. OmniSeq Insight interrogates the full exonic coding region of 523 genes by next generation sequencing. The clinical documentation in the case file does not support that the requested testing is medically reasonable and necessary and is expected to impact the management and outcome of the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSeq Insight Panel test have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the left knee x-ray provided on May 11, 2021.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the diagnosis code is mismatched.
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 the billed diagnosis code M17.11 (Unilateral primary osteoarthritis, right knee) is not supported in the medical record. Specifically, the x-ray was provided on the right knee. It is inappropriate to bill right-sided diagnosis code for services provided to the right side.
Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the left knee x-ray provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external electrocardiogram recording provided on January 25, 2021.
You asked the Plan to waive the copayment for the electrocardiogram. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $75 copayment for in-network diagnostic procedures and tests.
You have been asked to pay a $75 copayment for the external electrocardiogram recording. The external electrocardiogram recording falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the external electrocardiogram recording service was rendered. 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 external electrocardiogram recording provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on April 29, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that the x-ray was performed due to pain and
insurance should pay for the x-ray. The Plan denied your request. The Plan says the 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. Therefore, we decided that the Plan does not have to pay for the
intraoral x-ray provided on April 29, 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 need rehabilitation so you can be independent at home. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that you 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: 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. The Plan denied your request. The Plan says the records do not support the ability to tolerate an intensive rehabilitation therapy program.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for respiratory failure and coronavirus. Her medical problems are stable. 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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of extremity veins including responses to compression and other maneuvers (93971) and radiologic examination, knee (73562) provided October 24, 2020.
You asked the Plan to pay for the diagnostic services. You say that attached is the medical records for adjudication for the claim. Please reconsider and remit payment. The Plan denied your request. The Plan says services not supported without required documentation.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The primary payer is required to process and make primary payment on the claim. As the secondary insurer, the Plan cannot be held responsible for the diagnostic services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for duplex scan of extremity veins including responses to compression and other maneuvers (93971) and radiologic examination, knee (73562) provided October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Linx procedure (43284).
You asked the Plan to pre-approve the Linx procedure. You say that the 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 Linx procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration states that the LINX Reflux Management System is indicated for patients diagnosed with Gastroesophageal Reflux Disease (GERD) as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximum medical therapy for the treatment of reflux. The records do not show the enrollee meets these criteria. The record indicates that the enrollee had a Bravo pH test with a DeMeester score of 24.8. Manometry indicates gastroesophageal outflow obstruction.
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 a Linx procedure (43284).