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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the 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, you are mostly minimal assist for functional transfers and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for spinal levels L3, L5, and S1.
You asked the Plan to pre-approve the Intracept procedure. You say that it is felt that this particular surgery
would be best for the enrollee. The Plan denied your request. The Plan says this spinal procedure is not shown
to be medically reasonable and necessary in the current peer-reviewed literature.
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 Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has chronic back pain with lumbar radiculopathy. The requested
procedure remains experimental for the treatment of back pain with radiculopathy. More research is required 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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure for spinal levels L3, L5, and S1.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 8, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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 laboratory services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies
from January 13, 2020 to March 13, 2020.
You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you
disagree with the charges because you never had to pay in the past. 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 20%
coinsurance for prosthetic devices and related supplies.
You received prosthetic devices and related supplies on January 13, 2020. The total allowed amount is $524.31
and 20% of that is $104.85.
You received prosthetic devices and related supplies on February 12, 2020. The total allowed amount is
$538.31 and 20% of that is $107.65.
You received prosthetic devices and related supplies on March 13, 2020. The total allowed amount is $538.31
and 20% of that is $107.65.
The total amount you owe is: $320.15.
You have been asked to pay the total coinsurance amount of $320.15 for prosthetic devices and related
supplies. Prosthetic devices and related supplies falls within the prosthetic devices and related supplies benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies from
January 13, 2020 to March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided February 17, 2020.
You asked the Plan to pay for the progressive lenses. You say that the lenses should be covered since you had cataract surgery and post-cataract surgery eyewear is covered. The Plan denied your request. The Plan says only basic lenses are covered under the Medicare benefit. The allowance can only be applied to non-Medicare covered items obtained from network vision providers.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $200 allowance for vision items not covered by Medicare, but only when obtained through in-network vision providers. We looked at the file and the Plan's rules. Only basic lenses are covered under the Medicare Cataract benefit. The progressive lenses are non-covered by Medicare. The $200 allowance from the plan can only be applied to items obtained from network providers. The lenses were obtained out-of-network. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for twenty additional dental extractions (D7140 x 20) and removal of lateral exostosis (maxilla or mandible) (D7471) provided to the enrollee on November 11, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the enrollee exhausted their benefit.
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 enrollee exhausted their benefit, because the Plan approved and paid three (3) dental extractions. The enrollee's EOC states, Extractions (Pulling Teeth) - Frequency/Limitations - Three (3) procedures per calendar year. Therefore, the twenty additional dental extractions (D7140 x 20) are not covered. Furthermore, removal of lateral exostosis (maxilla or mandible) (D7471) service not covered is not listed in the enrollee's EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for twenty additional dental extractions (D7140 x 20) and removal of lateral exostosis (maxilla or mandible) (D7471) provided to the enrollee on November 11, 2019 by an out-of-network provider.
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 IRF services are medically necessary.The Plan denied your request. The Plan says 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 there is no documentation of a need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRFWe 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on February 5, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the charges because you feel that the ultrasound should be considered a breast cancer screening service.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say aplan 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 $35 copayment for X-rays.The medical records show that you received an ultrasound on February 5, 2020. Ultrasounds are not included in breast cancer screenings. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ultrasound provided on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 30, 2020 through April 6, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that it was not your fault that you had COVID-19 and needed to go to the hospital. The Plan denied your request. The Plan says copayments are only waived for COVID-19 testing and not treatment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on March 30, 2020 and discharged on April 6, 2020. You were asked to pay a $250 copayment per day from March 30, 2020 through April 5, 2020, days 1-7 of your inpatient hospital care. You were discharged on April 6, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-7. Furthermore, copayments are only waived for COVID-19 testing and not treatment. 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 inpatient hospital care from March 30, 2020 through April 6, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve foot surgery (28304 and 28308).
You asked the Plan to pre-approve the foot surgery. You say that you would like reconsideration because you have had problems with bone spurs for years. The Plan denied your request. The Plan says that you should have another trial of orthopedic use prior to surgical intervention.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the foot surgery. Our reviewer says that surgical correction with removal of osteophyte dorsal aspect of left mid-foot is medically reasonable and necessary. Our physician reviewer found Medicare guidelines state that Medicare will cover treatments that will improve a malfunctioning body member. An abnormal osteophyte to the dorsal aspect of the first metatarsal first cuneiform joint is abnormal and can create a malfunctioning joint. Removal of a dorsal osteophyte of the foot is considered safe and effective and is standard of care to treat this painful pathology. 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 foot surgery have been met. Therefore, we decided that the Plan has to pre-approve foot surgery (28304 and 28308).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 2, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan covers 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 laboratory services. 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 laboratory services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715), a hepatitis A vaccine (90632), and administration (90471, 90472) provided on December 2, 2019.
You asked the Plan to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine, a hepatitis A vaccine, and administration. You say that you were told this would be covered. The Plan denied your request. The Plan says coverage of these vaccines is the responsibility of your Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria toxoids and acellular pertussis vaccine, a hepatitis A vaccine, and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus, diphtheria toxoids and acellular pertussis vaccine, a hepatitis A vaccine, and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715), a hepatitis A vaccine (90632), and administration (90471, 90472) provided on December 2, 2019.
Benefits for a tetanus, diphtheria toxoids and acellular pertussis vaccine, a hepatitis A vaccine, and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracapsular cataract removal services and posterior chamber intraocular lens provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the extracapsular cataract removal services and posterior chamber intraocular lens provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora physical therapy evaluation (97163) provided on August 26, 2019.You asked the Plan to pay for the physical therapy evaluation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed codes does not appropriately reflect the services provided by the physical therapist assistant.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 97163 is Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. 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 physical therapy evaluation. Our reviewer says that CPT code 97163 does not meet criteria for billing or reimbursement consideration. Our physician reviewer found the documentation does not support that there was clinical decision making of high complexity by a licensed physical therapist.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 physical therapy evaluation have not been met.Therefore, we decided that the Plan does not have to pay fora physical therapy evaluation (97163) provided on August 26, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve UriCap external urine collection devices.You asked the Plan to pre-approve UriCap external urine collection devices. You say that your inability to walk and incontinence is hazardous to your overall health.The Plan denied your request. The Plan says that Medicare excludes items related to incontinence.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 UriCap external urine collection devices. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the enrollee does have documentation of permanent urinary incontinence (duration of at least 3 months). Based on the Local Coverage Article: Urological Supplies -Policy Article (A52521): Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Although the enrollee's medical problem list includes the diagnosis of obstructive uropathy all of the notes describe incontinence (not retention).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of UriCap external urine collection devices have been met.Therefore, we decided that the Plan has to pre-approveUriCap external urine collection devices.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 toopen the case again, we will send you a letter.