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

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 6, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that social security is your only income. You say that the copayment should be paid for you. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" 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 ER visit provided on October 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided by the Laboratories on September 30, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided by the Laboratories on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea hypoglossal nerve stimulation procedure to treat obstructive sleep apnea.You asked the Plan to pre-approvethe requested services. You say that the procedure is necessary for the treatment of your condition.The Plan denied your request. The Plan says the requested service is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coveragehave not been met. Therefore, we decided that the Plan does not have to pre-approvea hypoglossal nerve stimulation procedure to treat obstructive sleep apnea.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by Town of Billerica on October 3, 2019. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the charges because if you had not been released too soon you would not have needed the ambulance trip. 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 $275 copayment for ambulance services.  
 
You have been asked to pay a $275 copayment for an ambulance trip. An ambulance trip falls 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 an ambulance trip provided by Town of Billerica on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crown and pontic.
You asked the Plan to pre-approve the retainer crown and pontic. You say that x-rays show decay under bridge abutment on tooth #15. You say that a new bridge is needed. The Plan denied your request. The Plan says the services are not medically necessary.
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 retainer crown and pontic when the services are medically necessary and reasonable. 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 retainer crown and pontic. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer says that a three unit bride is not medically necessary because there is no precluding physical or psychological condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crown and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve the retainer crown and pontic.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802) provided on September 11, 2019.
You asked the Plan to pay for medical nutrition therapy. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee does not have diabetes or a renal disease.
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy is covered for certain beneficiaries who have diabetes or a renal disease. We looked at the file and Medicare rules. The records do not show that the enrollee has diabetes or a renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97802) provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift.
You asked the Plan to pay for a stair lift. You say that you have lived in your home for over 35 years and you
do not feel you should have to move to accommodate your health issues when a stair lift meets your needs. The
Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you refused transport because you could not leave your sister and you needed to stay home to help her.The Plan denied your request. The Plan says these services are not a covered benefit.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 August 4, 2019. 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 the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 9, 2019 through November 5, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that she was sent for a central line change only and admission was done without permission. You say that the charges should be reconsidered.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment per admission.The enrollee has been asked to pay a $125 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that 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 in the Plan. Therefore, we decided that the Plan does not haveto waive the copayment forthe inpatient stay provided from October 9, 2019 through November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour next test strip.You asked the Plan to pre-approve Contour next test strip. You say that the items are necessary.The Plan denied your request. ThePlan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as theenrollee retains access to all medically necessary items (including non-preferred brands). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour next test strip have not been met. Specifically, medical records were not provided. Without this documentation medical necessity for the specific brand requested is not able to be established.Therefore, we decided that the Plan does not have to pre-approveContour next test strip
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was an elective admit to acute care on 3/20/20 for spinal surgery. She is now status post removal of instrumentation and re-instrumentation T2-S1. The enrollee's prior level of function was being independent for activities of daily living and modified independent (used cane) with ambulation. The enrollee lives with spouse in single level home with 1 step to enter. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple therapies such as physical therapy and occupational therapy, however the documentation does not support that this enrollee requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve the Gene Analysis full sequence test.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansayswhole exome sequencing is not a standard of practice at this time.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 test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have anemia and hypercoagulability. Multiple prior genetic studies have been non-diagnostic. Further genetic testing has been ordered, but without any specific diagnosis in mind, random screening/testing is not medically reasonable or necessary. There is no evidence to support that such testing would result in discovery of a treatable diagnosis.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 test have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Gene Analysis full sequence test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on August 2, 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 J9042 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 J9042 is injection, brentuximab vedotin, 1 mg.We find that CPT code J9042 is not supported in the medical record. Specifically, there is no documentation thatan injection of brentuximab vedotin was administered. 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 forthe services rendered to enrollee on August 2, 2019.
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 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pancreatitis and associated complications. The enrollee had a recent decline requiring intubation. She has not yet received a tracheotomy and her long-term goals/treatment plans are not yet established. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 pay for physician's services provided on August 12, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says rehab needs are not complex, and an interdisciplinary approach is not required, with multiple specialists to oversee rehab care.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's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The enrollee's debility can be appropriately treated by progressing his mobility with the physical therapy treatments being provided. He is ambulating greater than household distances and performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at an SNF level. 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee will receive the appropriate level of care in the acute rehabilitation setting. You say that further delay will have a detrimental effect on the enrollee'ssafety, ability, to recover to the fullest extent, being discharged to a community setting and stay in that community setting, and averting unplanned readmissions.The Plan denied your request. The Plan says the guidelines for coverage have not been met.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required theintensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical therapy and occupational therapy, but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on June 20,
2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says payment for this service is
included in payment to the facility and not separately reimbursable for this provider in this place of service.
The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished
to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the moderate sedation services have not been met. Specifically, payment for this service is
included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for moderate
sedation services (99153) provided on June 20, 2019.