Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. You will not be able to tolerate the intensity of an IRF level of therapies and make a significant functional improvement in a predicted period of time. Your rehabilitation needs can be met at a lower intensity setting such as in a skilled nursing facility or at home with services. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99203)and the x-ray exam of the cervical spine (72040) provided on October 30, 2019.You asked the Plan to pay forthe office visit and the x-ray exam of the cervical spine. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99203)and the x-ray exam of the cervical spine (72040) provided on October 30, 2019.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is
mostly total/maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive,
longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit
and/or participate in an IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment for eye services received on January 23, 2020.
You asked the Plan to waive the copayment for the services. You say that you have been harassed by bill collection. The Plan denied your request. The Plan says that you received an additional diagnostic procedure.
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 does not say in clear and accurate terms that an additional diagnostic copayment may be due for eye exams. We looked at your contract with the Plan. The plan does not specify that a copayment will be applied for any additional services received during an eye exam. The service you received - CPT 92134 - is a Medicare-covered vision service, so it should have no copayment according to your contract. The Plan contract clearly says how much enrollees must pay for vision services - $0. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for eye services received on January 23, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services needed in other settings.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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-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 orthopedic services provided on February 27, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 has network providers available who can provide the services 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 these services. Therefore, we decided that the Plan does not have to pay for orthopedic services provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2019 gym membership.You asked the Plan to pay for2019 gym membership. You say that you were not aware of this requirement and would like the Plan to make an exception.The Plan denied your request. The Plan says to be eligible for reimbursement qualified membership dues must be received no later than 31 days following the end of plan year. The Plan states this is stated in Plan contract and in the instructions (#4) of the reimbursement form. The Plan states that your request for reimbursement was received April 18, 2020, which surpassed the January 31, 2020 deadline for reimbursement for April 2019 through December 2019.  Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Based on the records provided, you did not submit your reimbursement request within the required time frame stated by the Plan contract and the reimbursement instructions. The Plan's rules for coverage of gym benefits have not been met. Medicare does not make exceptions to supplemental gym benefits. Therefore, we decided that the Plan does not have to pay for2019 gym membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bite wings (D0274) provided on February 25, 2020.You asked the Plan to pay for the bitewings. You say that you were given a list of non-covered services with prices by the providers office, but you declined them all. You also say you were not informed that bite wing x-rays were not a covered benefit.The Plan denied your request. The Plan says this service is not covered by the Plan.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. The only x-rays that are covered by your plan are complete series of intraoral x-rays(D0210) and panoramic x-ray (D0330).Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forankle foot orthosis (L1971) provided December 30, 2019.You asked the Plan to pay forthe orthosis. You say that you are submitting supporting documentation. A thorough review reveals that you dispensed medically necessary supplies pursuant to physician orders, which were received by the enrollee.The Plan denied your request. The Plan says the records provided do not support the service billed.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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of an ankle disorder, nor is there a physical examination of the ankles and feet. 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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forankle foot orthosis (L1971) provided December 30, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless forthe urgent care visit and x-ray services received on August 26, 2019.You asked the Plan to pay forthe urgent care visit and x-ray services. You say that you paid your copayment amount and now you are receiving a bill for $425.The Plan denied your request. The Plan says that non-contracted providers are not to balance bill members.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $25 copayment for urgently needed services. The Plan says that non-contracted providers are not to balance members. However, you are being asked to pay $425 additional in fees for the services received on August 26, 2019. Based on the Plan contract, however, you cannot be asked to pay more than a $25 copayment for the x-ray services.Therefore, we decided that the Plan has to hold you harmlessforany additional fees over the $25 copayment for the urgent care visit and x-ray services received on August 26, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions and topical application of fluoride excluding varnish provided on March 12, 2020.
You asked the Plan to pay for the oral hygiene instructions and topical application of fluoride. You say that you were not informed of the additional costs for these services and they were provided to you without your approval. You also say that a Plan representative told you that it would be done twice a year for free. The Plan denied your request. The Plan says these services are not covered.
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 oral hygiene instructions and topical application of fluoride excluding varnish provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 24, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only whenthe patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provider on February 15, 2020.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provider on February 15, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gym membership fees from December 1, 2019 to December 31, 2019.You asked the Plan to pay forthe gym membership. You say that The monthly contract is $38.50 a month. This is charged to your credit card automatically. The attached copy is for the December charge.The Plan denied your request. The Plan says requests for reimbursement of qualified membership dues may be submitted monthly but must be received no later than 31 days following the end of plan year.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only the plan reimburses up to the annual benefit of $500 for monthly membership dues to an approved community fitness center..The Plan's rules for coverage of gym benefits have not been met because requests for reimbursement of qualified membership dues may be submitted monthly but must be received no later than 31 days following the end of  the plan year. This request was not submitted until February 18, 2020.Therefore, we decided that the Plan does not have to pay forthe gym membership fees from December 1, 2019 to December 31, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by an out-of-network provider on February 29, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 ambulance services/ground. You have been asked to pay a $250 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services falls within the ambulance services/ground benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided by an out-of-network provider on February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI), also known as nuclear stress testing.
You asked the Plan to pre-approve the MPI. You say that the enrollee has edema and had abnormal findings on an EKG including RSR and an old anterior infarct. He cannot do a stress echo due to being wheelchair-bound. The Plan denied your request. The Plan says the criteria for this nuclear imaging have not been met.
The Plan follows Medicare rules. Medicare rules say that MPI may be covered for certain indications as detailed 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 the MPI. Our reviewer says that the documentation does not support the medical necessity of this testing. Our physician reviewer found based on the records, the patient has some coronary risk but no cardiac symptoms, no cardiac exam abnormalities and nonspecific poor R wave progression on electrocardiography that are not diagnostic of old infarction and may be related to lead misplacement or a normal variant. In this circumstance, the diagnosis of old infarction is not established or secure. As such, an echocardiogram to assess regional anterior wall motion is reasonable and appropriate. A nuclear stress test would be considered appropriate only if regional dysfunction were identified on echocardiography. Coverage criteria for nuclear stress testing is not currently met since there are no documented covered indications for the procedure. 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 MPI have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI), also known as nuclear stress testing.