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

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 28, 2019 to March 4, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary and appropriate for the entire stay. The Plan denied your request. The Plan says that the treatment could have been provided on an alternative level of care to monitor. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital on February 28, 2019 with palpitations, right upper arm pain, and cold sweats. An echocardiogram and a cardiology consult were planned. Given the enrollee's age, her significant cardiac history, and the diagnosis it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 28, 2019 to March 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 27, 2019.You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 must 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 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 out of network physician services provided to the enrollee on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203, 99213).
You asked the Plan to pre-approve these services. You say that you are in intense pain from ongoing sciatic problems. You also say that you have been receiving chiropractic care for over ten years with your previous health plan and would like to continue. The Plan denied your request. The Plan says this service is not a covered benefit by the health plan.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve the office visit (99203, 99213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental pneumatic appliance/sleeve (E0667).
You asked the Plan to pre-approve a pneumatic compression device and sleeve. You say that you request review of the records and reconsideration for authorization. The Plan denied your request. The Plan says the criteria is not met as the enrollee does not have a failed four week trial of E0650 or E0651. Therefore, E0667 is noncovered when requested in conjunction with the non-approved code E0652.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental pneumatic appliance/sleeve (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal procedure (code D4999) provided on October 16, 2019.
You asked the Plan to pay for the periodontal procedure. You say that you cannot pay for this service. The Plan denied your request. The Plan says this service is not covered by your dental 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. Therefore, we decided that the Plan does not have to pay for the periodontal procedure (code D4999) provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom inserts provided to you on September 4, 2019.
You asked the Plan to pay for the inserts. You say that the foot inserts were prescribed as treatment for plantar fasciitis. The Plan denied your request. The Plan says you do not have a diagnosis of diabetes and these orthotics are not part of an integral brace.
The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. Inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan follows these same rules. We looked at the file and Medicare rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Based on this information, we decided that Medicare rules for coverage of the inserts have not been met. Therefore, we decided that the Plan does not have to pay for custom inserts provided to you on September 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care for the enrollee.You asked the Plan to pre-approve home health care. You say that home health care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on review of the records, after a month of treatments with nursing, physical therapy and occupational therapy, minimal progress is noted and agree Medicare coverage criteria are 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 home health care have not been met.Therefore, we decided that the Plan does not have to pre-approve home health care for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 3, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 17, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the enrollee, at the originating site. We looked at the file and Medicare rules. In this instance, the records do not show that the enrollee was present at an originating site located in a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or a country outside of an MSA served by the telehealth network. Additionally, the record does not show that the encounter was conducted using an audio and video telecommunication system. 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 for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided on October 18, 2019.
You asked the Plan to waive the coinsurance for an injection. You say that you are being billed this amount incorrectly. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay less than a 20% coinsurance of the allowed amount for an injection. The allowed amount is $1,400.18. The 20% coinsurance is $280.04 ($1,400.18 x 20% = $280.04). The total amount you are being asked to pay is $279.73 which is less than your coinsurance amount of $280.04. An injection falls 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 coinsurance for an injection provided on October 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visits provided from June 27, 2019 to October 15, 2019.
You asked the Plan to pay for the physician services. You say that the services provided to the enrollee are not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the rest home visits provided from June 27, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, one or more areas, each 15 minutes (97110) provided October 8, 2019.You asked the Plan to pay for code 97110. You say that physical therapy services provided to the enrollee on October 8, 2019. The Plan denied your request. The Plan says the billed service 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.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 code 97110. Our reviewer says that code 97110 is not supported by the medical records. Our physician reviewer found the service does appear to have been billed twice. There is no evidence that a second set of services was provided on the date of service in question. There is no evidence that the provider being denied payment provided any services on the date of service in question. The documentation does not support the billing of the denied 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 code 97110 have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, one or more areas, each 15 minutes (97110) provided October 8, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the posterior resin-based composite, two anterior resin-based composites, and two periodontal maintenance procedures provided from February 14, 2019 to September 23, 2019.
You asked the Plan to pay for the resin-based composites and periodontal maintenance. You say that your lower teeth were found to have periodontal disease and it took years to get it under control. You also say that you had to have fillings to replace ones that had fallen out. The Plan denied your request. The Plan says periodontal services and fillings are excluded from your 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. Therefore, we decided that the Plan does not have to pay for the posterior resin-based composite, two anterior resin-based composites, and two periodontal maintenance procedures provided from February 14, 2019 to September 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 the records provided support the need for SNF care. The Plan denied your request. The Plan says that the notes provided do not show a need for skilled nursing care or skilled therapy care in a skilled therapy facility. The Plan says that the need for custodial care can be provided in a long-term care facility.
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 requires oversight of her medical conditions and medication management. Our physician reviewer found that the enrollee is at risk for secondary complications of immobility, such as pressure ulcers and contractures as well as further fall-related injuries. The enrollee has a history of a current pressure ulcer and requires assistance of more than 1 person for essential activities of daily life. A trial of skilled therapy is indicated. The enrollee requires both daily skilled therapy and nursing services. The enrollee is unable to perform essential activities of daily living such as bed mobility without assistance from more than one person. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. A trial of SNF level care with the reasonable expectation of a reduction in burden of care is medically necessary. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services for placement of a ureteral stent provided on August 8, 2019.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized by the Plan before the services are provided.
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 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 outpatient hospital services for placement of ureteral stent provided on August 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen.You asked the Plan to pre-approve Privigen. You say that Privigen is medically necessary. The Plan denied your request. The Plan says there is not enough clinical evidence to support the use of Privigen when used for the prevention of infection prior to surgery.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Privigen. Our reviewer says that Privigen is not medically necessary at this time. Our physician reviewer found Privigen is not indicated for surgical prophylaxis in a patient with hypogammaglobulinema who is not currently receiving Privigen or has signs of recurrent infection. This is not a standard practice. The service is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, hip orthosis, and addition to lower extremity provided on September 17, 2019.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397), hip orthosis (L1686), and addition to lower extremity (L2624). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not met.
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 knee orthoses (L1851) and suspension sleeves (L2397), hip orthosis (L1686), and addition to lower extremity (L2624). Our physician reviewer found the enrollee's chief complaints were chronic pain in the hip right, and knee left, and knee right. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
The documentation in the case file does not support that the requested hip orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the hip would reasonably be required to adequately assess whether the hip orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the hip. 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 knee orthoses (L1851) and suspension sleeves (L2397), hip orthosis (L1686), and addition to lower extremity (L2624) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, hip orthosis, and addition to lower extremity provided on September 17, 2019.