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

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the facility has no Covid cases.The Plan denied your request. The Plan says you do not need a rehab doctor 3 times a week, or an intensive team for rehab care.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 physician reviewer found that you are at minimal assist level for standing, contact guard assist for walking using a rolling walker,independent with eating, moderate assist for toileting, maximumassist for bathing, and moderate assist for dressing. You donot require the intensity of services provided at an IRF. Specifically, you arenot shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental service.
You asked the Plan to pre-approve the dental service. You say that you were not informed that the provider was out of network prior to the service being rendered. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that you must see a contracted provider for the service to be covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pre-approve the dental service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forparenteral nutrition solution (B4185, B4197, B4220 and B4224) provided on June 4, 2020, through June 10, 2020.You asked the Plan to pay forthe parenteral nutrition solution. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not include an itemized shipping/billing invoice or proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the documentation submitted does not include proof of delivery for the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forparenteral nutrition solution (B4185, B4197, B4220 and B4224) provided on June 4, 2020, through June 10, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 12, 2020.You asked the Plan to pay forthe ambulance services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered were not medically necessary.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the documentation does not support that the ambulance services were medically reasonable or necessary. Our physician reviewer found the documentation supports that upon ambulance arrival, the enrollee was sitting, conscious and alert and oriented, and with no indications of injury. The documentation supports that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were not contraindicated for the enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on July 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on July 6, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you were not aware of the charges and cannot afford them. 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 $110 copayment for each radiological diagnostic service. You received two ultrasounds on July 6, 2020. Therefore, you are responsible to pay a $110 copayment per each ultrasound. The total amount you owe is: $220. You have been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds fall 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 copayments for ultrasounds provided on July 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) stay from February 1, 2020 to February 19, 2020.You asked the Plan to waive the copayment forthe SNF stay. You say that you believe you are being billed for a hospital stay, not a SNF stay.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 $0 copayment each day for days 1 to 20and a $176 copayment for days 21 to 100 for skilled nursing facility (SNF) care. You have been asked to pay a total cost share of $1,584 for the 29 days(December 11, 2019, to December 20, 2019; January 30, 2020 to January 31, 2020; and February 1, 2020to February 19, 2020)you spent receiving SNF care for the coverage period (9 days x $176 = $1584).The services provided fall within the skilled nursing facility (SNF) 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 forthe skilled nursing facility (SNF) stay from February 1, 2020 to February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe lab testing provided on June 17, 2020.You asked the Plan to waive the copay forthe services provided. You say that you were told your visit would be free.The Plan denied your request. The Plan says the lab work was not covered under your yearly physical.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 $10 copay per day, per provider, for Medicare-covered lab services. You havebeen asked to pay a $10 copay for the lab services. The services fallwithin the outpatient diagnostic tests 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 copay forthe lab testing provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis rendered on March 16, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. There is no valid proof of delivery in the 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 forthe lumbar-sacral orthosis rendered on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) for tooth # 19.

You asked the Plan to pre-approve a crown for tooth # 19. You say that the crowns are medically necessary.The Plan denied your request. The Plan says 1 crown per tooth, per 60 months is covered. The Plan also says that the frequency limit has been reached.

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 frequency limit of 1 crown per tooth, per 60 months, has been reached. The record shows that the Plan paid for a crown for tooth # 19 that the enrollee received.Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) for tooth # 19.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from November 5, 2017 to November 9, 2017.You asked the Plan to pay foracute inpatient hospital care. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of payment for this inpatient hospital care is correct, because this inpatient care was 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 enrollee presented with abdominal cramping and malodorous urine. Examination findings were benign. He was treated with antibiotics and intravenous fluids and urine was cultured. He was admitted to the hospital for catheter exchange. Considering the potential infection recurrence, complication of urinary tract infection involving the suprapubic catheter, it is complex enough to justify inpatient admission and due to the need to await culture results, change the catheter, and monitor for improvement prior to discharge, it was expected that hospital carewould span at least 2 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 November 5, 2017 to November 9, 2017.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit or waive the cost share for the chiropractic services provided.

You asked the Plan to pay for the office visit and waive the cost share for the chiropractic services. You say that you needed the services for pain relief.The Plan denied your request. The Plan says you were charged the deductible and coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance and a $198 deductible for Chiropractic Services. 

You have been asked to pay 20% coinsurance and a$198 deductible for the chiropractic services.The chiropractic services fall within the Chiropractic 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.The office visit is not covered under your chiropractic service benefit. Therefore, we decided that the Plan does not have to pay for the office visit or waive the cost share for the chiropractic services provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. He has not tried and failed the Plan's required drugs of Durolane or Synvisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Supartz FX is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor provided on February 24, 2020.
You asked the Plan to pay for blood glucose monitor. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of payment for this item is correct, because the records do not
support coverage for the item billed.
The Plan must follow Medicare rules. Medicare rules say that if a supplier bills for a blood glucose monitor
without first receiving a completed standard written order, the claim will be denied.
We looked at the file and Medicare rules. The physician's order for this item is dated June 17, 2020; therefore,
the documentation submitted does not show that you received a standard written order before furnishing the
billed item. Based on this information, we decided that Medicare rules for coverage of blood glucose monitor
have not been met. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor
provided on February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap services coded 15733 provided on June 8, 2020.
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap services. 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 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae). We find that CPT code 15733 is not supported in the medical record. Specifically, the operative report did not include documentation of a muscle, myocutaneous, or fasciocutaneous flap, from the head and neck with named vascular pedicle (buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the muscle, myocutaneous, or fasciocutaneous flap services have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap services coded 15733 provided on June 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound and biopsy provided from
August 27, 2020, to September 1, 2020.
You asked the Plan to waive the copayments for ultrasound and biopsy. You say that you thought that
Medicare would pay for what the Plan did not pay. The Plan denied your request. The Plan says the copayment
amounts you are being charged are correct.
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 $100
copayment for ultrasound and $350 copayment for biopsy. For the ultrasound, you have been asked to pay the
allowed amount of $93.54, because this amount is less than the $100 copayment for ultrasounds. Your total
cost-sharing responsibility is therefore $443.54.
You have been asked to pay less than $100 copayment for ultrasound and $350 copayment for biopsy.
Ultrasound and biopsy fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and
"Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers" benefit categories. 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 copayments for an ultrasound and biopsy
provided from August 27, 2020, to September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe osseous surgery (D4261) and guided tissue regeneration (D4266) provided on July 21, 2020.You asked the Plan to pay forthe osseous surgery and guided tissue regeneration. You say that you would like the claim reprocessed and approved for payment.The Plan denied your request. The Plan says regarding the osseous surgery, the claim processed according to the contract. Furthermore, regarding the guided tissue regeneration this service is not covered by your Plan under any circumstances.Medicare generally does not cover dental services. However, the Plan offers adental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says thatthere is a $100 deductible followed by a 50% coinsurance for major dental services.The osseous surgeryyou asked the Plan to pay forfalls within the benefit category major dental services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 deductible formajor dental services. This cost sharing is a contractual obligation that had not been met at the time. Further, you are also being charged a coinsurance of 50% ($141 allowed amount -$100 deductible = $41 x 50% coinsurance = $20.50). Although you are covered for this service, because the provider is out-of-network they are allowed to bill the difference of the allowed amount and the billed amount. Though the Plan offers a dental benefit in excess of Medicare coverage, guided tissue regeneration is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe osseous surgery (D4261) and guided tissue regeneration (D4266) provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.