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

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (xrays)
and extractions provided on January 29, 2020.
You asked the Plan to pay for the x-rays and extractions. You say that the extractions were medically necessary
in order to receive dentures. The Plan denied your request. The Plan says that this request exceeds the benefit
limit.
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 full mouth or
panoramic x-rays are covered one procedure every three years and extractions are covered three procedures per
calendar year.
We looked at the file and Medicare rules. The file indicates the plan paid for a complete x-ray on January 6,
2020 and three extractions on January 29, 2020. Based on this information, we decided that the Plan's rules for
coverage of the x-rays and extractions have not been met. Therefore, we decided that the Plan does not have to
pay for the intraoral - complete series of radiographic images (x-rays) and the additional extractions provided
on January 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech language therapy pathology services provided from October 15, 2019 to October 30, 2019. 
 
You asked the Plan to pay for the speech language therapy pathology services. You say that the hospice services were discontinued on October 6, 2019. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 6, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the speech language therapy pathology services provided from October 15, 2019 to 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not 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 enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The documentation does not support that her functional level 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 11, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include test results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.
You asked the Plan to pre-approve the aquatic therapy. You say that you would like reconsideration because
physical therapy his needed to decrease pain, maintain function and enable mobility. The Plan denied your
request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 aquatic therapy. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the member should be able to transition to a home exercise program.
The requested services are not part of a maintenance program and the specialized skill, knowledge and
judgement of a qualified therapist is not required to establish, design or deliver a program to maintain the
member's current condition or prevent deterioration.
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 aquatic therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve aquatic therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the daptomycin injections provided from December 8, 2019 through December 31, 2019.
You asked the Plan to waive the cost for the daptomycin injections. You submitted your bill for review. The Plan denied your request. The Plan says that the lower cost sharing amount applied is being upheld.
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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $10, which is less than the standard 20% coinsurance for each daptomycin injection. The total amount you owe is $240 ($10/injection x 24 injections = $240). The daptomycin injections fall within the "Medicare Part B Prescription Drugs' 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 cost for the daptomycin injections provided from December 8, 2019 through December 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 19, 2020.You asked the Plan to waive the copayment for an office visit. You say that this was a preventative physical exam and you should not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide medical records. Without medical records we cannot determine whether services received were preventative or not.Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for amalgam - two surfaces, primary or permanent (D2150) and
amalgam - three surfaces, primary or permanent (D2160) provided on March 4, 2020.
You asked the Plan to pay for the dental services. You say that you do not know why the fillings are not
covered when they have been covered in the past. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 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.
Your Plan that states composite resin (white) restorations on a posterior tooth are not covered and the Plan will
pay only the applicable amount that it would have paid for amalgam (metal) restoration. You will be
responsible for the difference in the cost. Therefore, we decided that the Plan does not have to pay for amalgam
- two surfaces, primary or permanent (D2150) and amalgam - three surfaces, primary or permanent (D2160)
provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Guardant360 gene panel provided to the enrollee on October 2, 2019.You asked the Planto payforthe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is intended for individuals with advanced-stage solid tumors.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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee reportedly hasmetastatic cervical cancer. Testing specifically related to cervical cancer and for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to cervical cancer or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested panel testing was medically necessary or reasonable.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Guardant360 gene panel provided to the enrollee on October 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 6, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 $90 copayment for in-network emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room 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 emergency room visit provided on January 6, 2020.
Your complaint about the misdiagnosis at the emergency visit 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 9, 2020.
You asked the Plan to waive the copayment for an urgent care visit. You say that you thought that you would only owe a $15 copayment. 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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for an urgent care visit. An 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 waive the copayment for an urgent care visit provided on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance rides provided from March 18, 2020 to March 23, 2020.You asked the Plan to waive the copayment forthe ambulance rides. You say that you do not know why you are being charged for the ambulance rides. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services. For each date of service, you have been asked to pay the allowed amounts of the claims because these amounts are less than the $125 copayments for the ambulance rides.The enrollee has been asked to pay a $47.94 copayment for the ambulance rides on March 18, 2020 and March 23, 2020. You have also been asked to pay a $45.90 copayment for the ambulance ride on March 20, 2020. The ambulance rides fall within the "Ambulance services" 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 have to waive the copayment forthe ambulance rides provided from March 18, 2020 to March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH are not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records, the enrollee still requires acute care. However, the records do not suggest that at least 25 days of LTACH stay would be needed. Insufficient weaning attempts have been made. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. As acute care services are already being appropriately provided, the request for LTACH services will be considered not medically necessary at this time. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the extraction, erupted tooth or exposed root, (elevation and/or forceps removal) (D7140) provided February 27, 2020.
You asked the Plan to pay for the extraction. You say that you want to file an appeal for this to be covered. You would like to be reimbursed for what you paid for out of pocket at the dental office. The Plan denied your request. The Plan says that this service is not considered a simple tooth extraction and is therefore 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. The Plan covers the extraction and D7140 is a simple extraction code and should be covered up to the $200 allowance. Based on this information, we decided that the Plan's rules for coverage of the extraction have been met. Therefore, we decided that the Plan has to pay for the extraction, erupted tooth or exposed root, (elevation and/or forceps removal) (D7140) provided February 27, 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-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 inpatient rehabilitation facility 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 your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not indicate that you have significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility. You require significant assistance for functional transfers and activities of daily living. It is not clear that you would be able to fully benefit and/or participate in an inpatient rehabilitation facility level of care. A less intensive, longer duration of therapy may be more appropriate. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 proton beam therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that while they do not believe proton therapy is an experimental therapy, any potential benefit or detriment of proton therapy over standard intensity-modulated radiation therapy (IMRT) for routine cases is investigational. Coverage criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 25, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 on July 25, 2019.