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

We decided that the Plan has to pay forthe acute inpatient hospital care provided from September 15, 2019 through September 18, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 correctin 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 review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation 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 forthe acute inpatient hospital care provided from September 15, 2019 through September 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram, including computer-aided detection (77066) provided on September 11, 2019.
You asked the Plan to waive the copayment for a mammogram. You say that it looks like a mistake has been made. The technician who helped you seemed inexperienced as she had to redo several x-rays. You state you were upset with her comments that had never been said to you before. You feel you shouldn't be charged for a second visit as the process was the same as your prior visit. The Plan denied your request. The Plan says that each outpatient diagnostic test (including a diagnostic mammography) has a $70 copayment at an outpatient hospital setting.
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 $70 copayment for each outpatient diagnostic tests (including a diagnostic mammography). You have been asked to pay a $70 copayment for a mammogram. This service falls within the outpatient diagnostic tests (including a diagnostic mammography) benefit category. The allowable amount minus the Plan's portion equals your copayment ($104.86-34.86 = $70). 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 a diagnostic mammogram, including computer-aided detection (77066) provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the clinical information provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage haven not been met. The Plan says that the services needed could be provided in another setting.
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 the enrollee's ongoing care needs include wound vacuum care, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dilaudid 8mg for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that drug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDilaudid 8mg for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 11, 2019 by out of network provider.
You asked the Plan to pay for laboratory tests. You say that you are contracted with Medicare and a referral is not required. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and no valid referral was made for these services.
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 medical services provided on October 11, 2019 by out of network provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF care provided from August 9, 2019 to August 20, 2019.
You asked the Plan to pay for the SNF care. You say that you paid the required 14 day deposit from your personal account so the enrollee could be admitted to the facility. You also say that at this time there was no one who was able to provide care for the enrollee at home. The Plan denied your request. The Plan says that the enrollee did not receive skilled nursing level of care for the time period of August 9, 2019 to August 20, 2019. The Plan also says that the documentation does not support the need for daily skilled rehabilitation services.
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 pay for the SNF care. Our reviewer says that the enrollee did meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 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 pay for the SNF care provided from August 9, 2019 to August 20, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dent alveolar structures dental procedure provided on July 31, 2019.
You asked the Plan to pay for the dental procedure. You say that this procedure was necessary to complete the bone grafting and guided tissue regeneration. The Plan denied your request. The Plan says this service is an unlisted procedure.
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dent alveolar structures dental procedure provided on July 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (99070) provided in Mexico on June 24, 2019.
You asked the Plan to pay for the hospital services. You say that the services were emergent and should be covered. The Plan denied your request. The Plan says they have not received all the information needed to process payment for this claim.
The Plan must follow Medicare rules. Medicare rules say that services received outside of the United States are not covered. The plan contract allows emergency services received worldwide to be covered, however the enrollee must pay up front and request reimbursement by submitting a request, a bill and any documentation of the services received to the health plan. We looked at the file, plan contract, and Medicare rules. The plan has made multiple attempts to obtain an itemized bill and evidence of payment from the provider and the enrollee. No such documentation has been provided. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (99070) provided in Mexico on June 24, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician and nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services (CPT 99214) provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says hen an Evaluation and Management visit is reported within 90 days of a major surgical procedure, it will be bundled as part of the global surgical fee.
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 99214 is "office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity." We find that CPT code 99214 is not supported in the medical record. Specifically, this service was provided within the global surgical period, and is bundled as part of the payment for CPT 27071 - the surgery itself. CPT 99214 cannot be coded separately. 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 evaluation and management services (CPT 99214) provided to the enrollee on June 17, 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 you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
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
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on
January 8, 2020 to January 14, 2020 with acute renal failure. She was seen in a clinic for a follow up on
January 27, 2020 and admitted for renal failure. She was discharged home and had a decline due to constant
bilateral lower extremity pain and weakness. She currently needs minimal assist with transfers, supervision
with bed mobility, and modified assist with activities of daily living. The complexity of her patient's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. She may benefit from additional therapy but does not require an intensive
therapy program 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sulfasalazine tablets for the enrollee.
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Sulfasalazine tablets for the enrollee.
Benefits for self-administered drugs under Medicare Part B 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 Hepatitis A vaccination provided on September 27, 2019.
You asked the Plan to pay for immunization. You say that you were planning to go to Egypt and saw that this vaccination was recommended. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this vaccination is not covered by Medicare Part B. The Plan also says that this vaccine may be covered by Medicare Part D and you have been sent a Part D claim form for reimbursement.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to immunization. Therefore, we decided that the Plan does not have to pay for Hepatitis A vaccination provided on September 27, 2019.
Benefits for immunization 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: 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 enrollee meets the inpatient rehabilitation admission criteria under CMS guidelines. The Plan denied your request. The Plan says IRF care is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for high frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each (CPT Code E0483) provided to the enrollee on August 17, 2019, by an out-of-network provider.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. A chest wall oscillator is only covered when there is documentation of home oxygen dependence, failure of other treatments, and four recent hospitalizations for acute exacerbation of chronic obstructive pulmonary disease. Claims for the device without this history will be denied as statutorily non-covered, and not a benefit. Medicare non-coverage applies to both contracted and non-contracted providers, and cannot be overridden by plan directed care. Therefore, we decided that the Plan does not have to pay for high frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each (CPT Code E0483) provided to the enrollee on August 17, 2019, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on July 16, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says you need to submit medical records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. There are no medical records provided. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on July 16, 2018.