Persius/hicric huggingface dataset:
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 records provided support the medical necessity of IRF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. The plan says that the enrollee can receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 resides in an assisted living facility and has had a recent decline in function due to Parkinson's with multiple falls. Our physician reviewer found that the enrollee has not been recently hospitalized. Our physician reviewer found that the enrollee's prior level of function was contact guard/minimal assist with transfers, ambulation and activities of daily living. Our physician reviewer found that the enrollee's current level of function is minimal assist with bed mobility, moderate assist with transfers, moderate assist with ambulating, and moderate assist with dressing. Our physician reviewer found that the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. Our physician reviewer found that, while the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy for 3 hours per day and with frequent physician oversight and 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 waive the copayments for diagnostic imaging of the eye and the measurement of field of vision provided on October 24, 2019.You asked the Plan to waive the copayments for diagnostic imaging of the eye and the measurement of field of vision. You say that you disagree with 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 $10 copayment for x-rays, laboratory and other diagnostic tests.You received diagnostic imaging of the eye and the measurement of field of vision provided on October 24, 2019.Therefore, you are responsible to pay a $10 copayment per each diagnostic test. The total amount you owe is: $20.00.You have been asked to pay the total copayment amount of $20.00 for diagnostic imaging of the eye and the measurement of field of vision. Diagnostic imaging of the eye and the measurement of field of vision fall within the outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic imaging of the eye and the measurement of field of vision provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on August 10, 2019.
You asked the Plan to reduce the copayment for the urgent care visit. You say that you had to go to an urgent care or walk-in clinic and have never had to pay over $35 for a walk-in clinic before. The Plan denied your request. The Plan says you have been charged 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 $55 copayment for Medicare-covered urgently needed care visits. You have been asked to pay a $55 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 reduce the copayment for the urgent care visit provided on August 10, 2019.
Our decision is only about the August 10, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental consultation (D9310) intraoral-periapical first x-rays (D0220) pulp vitality tests (D0460) provided by the Physician on June 17, 2019.
You asked the Plan to pre-approve the dental services. You say that you only went to the dentist once time before this and does not understand how you used your x-ray benefits. The Plan denied your request. The Plan says the enrollee has exhausted the covered benefits for code D0220. Codes D9310 and D0460 are not listed as covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Intraoral -periapical x-rays are covered once a year and records show you already received this service on June 6, 2019. The dental consultation and the pulp vitality tests are not listed under the 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 pre-approve dental consultation (D9310) intraoral-periapical first x-rays (D0220) pulp vitality tests (D0460) provided by the Physician on June 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the drug test provided on August 13, 2019.
You asked the Plan to waive the copayment for the drug test. You say that you did not have a urine or blood test the day before. You say that you did not have any lab test on this date. The Plan denied your request. The Plan says the copayment 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 $15 copayment for each Medicare-covered lab test. You have been asked to pay a $15 copayment for the drug test. The drug test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were performed. 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 drug test provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 23, 2019.
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 procedure code G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation that 22 or more drug classes were tested. 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 drug testing rendered to the enrollee on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face down vitrectomy chair (E0190).
You asked the Plan to pre-approve a face down vitrectomy chair. You say that the requested item is necessary for your recovery after surgery. The Plan denied your request. The Plan says the item is considered a precautionary device and is not solely medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a face down vitrectomy chair (E0190).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, and the IT pump refill and re-program provided on September 17,2019.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services are available 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the office visit, and the IT pump refill and re-program provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) provided on March 7, 2019.You asked the Plan to waive the copayment fora hospital outpatient clinic visit. You say that you should not be charged for this service.The Plan denied your request. The Plan says this service processed 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 clearlysays that you must pay a $225 copayment for each Medicare-covered visit to an outpatient hospital facility. You have been asked to pay $128.97 for a hospital outpatient clinic visit. In this case, the allowed amount for this service is less than the $225 copayment listed in the EOC. 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 fora hospital outpatient clinic visit (G0463) provided on March 7, 2019.Your complaint about how your provider is billing services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Duplex Scan of the Lower Extremity (93926) provided May 26, 2019.
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the record does not support the codes 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 93926 is not supported in the medical record. Specifically, CPT code 93926 with modifier 50 is not supported by the medical records. The record states that an ultrasound of the right groin, femoral artery, and vein was performed. There is no evidence of a bilateral procedure. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for a Duplex Scan of the Lower Extremity (93926) provided May 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 29, 2019 to September 5, 2019.You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 29, 2019 to September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aid batteries provided on February 15, 2019.You asked the Plan to reimburse you for the hearing aid batteries. You say that the hearing aid batteries are medically necessary. The Plan denied your request. The Plan says hearing aid batteries are not a covered benefit according to your Plan.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.We looked at the file, Medicare's rules and the Plan's rules. The file shows that the Plan does not cover hearing aid batteries. Therefore, we decided that the Plan does not have to reimburse you for hearing aid batteries provided on February 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine provided on July 30, 2019.You asked the Plan to pay for the Tdap vaccine. The Plan denied your request. The Plan says preventative immunizations and their administration is not a Medicare-covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine.Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine provided on July 30, 2019.Benefits for the Tdap vaccine may be available under Medicare Part D.Contac tthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on April 23, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you have never had a copayment before. You say that your diagnosis does not warrant a copayment.The Plan denied your request. The Plan says the copayment 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 $15 copayment for Medicare-covered lab tests. You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forlaboratory services provided on April 23, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF services were recommended by physical therapy. You say that the enrollee is way below baseline and is not well enough to come home. You say that the enrollee needs antibiotics and oxygen. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for coverage of SNF care at this time. The plan says that the services needed by the enrollee are not required on a daily basis. The plan says that the enrollee's needs can be safely met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the criteria for coverage of SNF care have been met. Our physician reviewer found the enrollee was admitted to acute care on January 5, 2020 with shortness of breath and cough related to chronic obstructive pulmonary disease (COPD) exacerbation. Our physician reviewer found that the enrollee's prior level of function was living with his daughter in a one story home and modified independent with mobility and activities of daily living with a walker. Our physician reviewer found that the current level of function is ambulating with a wheeled walker 130 feet with minimal assist, transferring with minimal assist, minimal assist with bed mobility, maximal assist with dressing, and dependent with bathing. Our physician reviewer found that the records support that the enrollee needs daily physical and occupational therapy. Our physician reviewer found that the enrollee is significantly below his baseline level of function and would benefit from daily therapy to return to his baseline. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 4, 2019 to September 11, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 4, 2019 to September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 19, 2019 by the out of network provider.
You asked the Plan to pay for the practitioner services. You say that the services were provided to the enrollee at the request of the participating hospital. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 19, 2019 by the out of network provider.