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

We decided that the Plan does not have to waive the copayments forthe inpatient stays provided from June 20, 2019 through June 21, 2019 and August 3, 2019 through August 6, 2019 and the SNF stays provided from June 21, 2019 through July 15, 2019 and August 6, 2019 through August 30, 2019.You asked the Plan to waive thecopayments forthe inpatient stays and SNF stays. You say that the fractures weren't found until her second fall. You say that she should not have to pay anything.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee'scontract with the Plan clearly says that enrollees must pay a $175 copayment per day (Days 1-6 only) for each in-network Medicare-covered inpatient hospital stay. The enrollee's contract with the Plan clearly says that for in-network Medicare-covered skilled nursing facility care,enrollees must pay a $0 copayment per day,days 1-20, a $160 copayment per day, days 21-42 and a $0 copayment per day, days 43-100. 
The enrolleehas been asked to pay a total of $2,937.41for the inpatient stays and SNF stays. Date of ServiceServiceStandard CopaymentMember LiabilityJune 20, 2019 -June 21, 2019Inpatient Stay$175/day, days 1-6$175June 21, 2019 -July 15, 2019SNF Stay$0/day, days 1-20 and $160/day, days 21-42$800August 3, 2019 -August 6, 2019Inpatient Stay$175/day, days 1-6$525August 6, 2019 -August 30, 2019SNF Stay$160/day, days 21-42 and $0/day, days 43-100$1,437.41 -Met Maximum Out-of-pocketTOTAL:$2,937.41The inpatient stays fall within the "Inpatient hospital care" benefit category. The and SNF stays fall within the "Skilled nursing facility (SNF) care" benefit category. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe inpatient stays provided from June 20, 2019 through June 21, 2019 and August 3, 2019 through August 6, 2019 and the SNF stays provided from June 21, 2019 through July 15, 2019 and August 6, 2019 through August 30, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approvea semi-electric hospital bed (E0295). You say that the enrollee needs a semi-electric hospital bed because of fractures and medical condition.The Plan denied your request. The Plan says criteria have not been met.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We looked at the file, and Medicare rules. The documentation does not show an immediate need fora change in body position. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anticoagulant management for a patient taking warfarin (93793) provided on August 27, 2019 by out of network provider.You asked the Plan to pay foranticoagulant management. You say that you are appealing claim payment denial for services rendered to our member on date of service August 27, 2019.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 foranticoagulant management for a patient taking warfarin (93793) provided on August 27, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decidedthat the Plan does not have to pre-approve6 physical therapyvisits.You asked the Plan to pre-approvephysical therapy. You say that you are appealing the denied authorization so the enrollee can get physical therapy.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found thatthe enrollee has plateaued with gait and strength. Our physician reviewer found that sinceprogress is not being made, further therapy is not reasonable and 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 physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve6 physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee is in direct need of continued skilled nursing facility assistance. You say that the enrollee has been actively treated with a chronic ulcer to his left and right heel for greater than two years. You say that the enrollee has recently shown improvement with a multispecialty approach. You say that skilled nursing will increase the enrollee's chances of avoiding amputation, reducing infection risk and limit further complications.The Plan denied your request. The Plan says the enrollee's inpatient stay has reached the 100-day benefit limit for this admission.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 19, 2019 -January 15, 2020. The Plan has covered 100 days of SNF care.Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when care has not been received in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea medical alert systemYou asked the Plan to pre-approvethe medical alert system. You say that you have a history of falls and the requested device is medically necessary. You say that you would like to keep your independence. You say that your children are not nearby and you have had several instances that were emergent. You say that the last incident resulted in a fractured rib.The Plan denied your request. The Plan says medical alert systems are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that telephone alert systems are not covered.The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The item being requested is a telephone alert system and is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea medical alert system
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays and 4 periodontal scalings and root planings -four or more teeth per quadrant provided on August 14, 2019. We also decided that the plan does not have to pay for the core buildup, including any pins when required, and application of desensitizing resin for cervical and/or root surface provided on August 14, 2019.You asked the Plan to pay forthe intraoral x-rays, scalings and planings, core buildup, and application of desensitizing resin. You say that you initially made a $1,564 payment to have the dental work done. You also say that a customer servicerepresentative told you that the Plan owed you money.The Plan denied your request. The Plan says you are responsible for the $15 copayment for the x-ray and the $85 copayment per 
quadrant for the scalings and planings. The Plan also says that core buildup, including any pins when required and application of desensitizing resin for cervical and/or root surface are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when required, and application of desensitizing resin for cervical and/or root surface are not covered under this benefit. You have been asked to pay a cost-sharing amount for the x-rays and the scaling and planing. The contract clearly shows that you are responsible for a $15 copayment for each complete series of intraoral x-rays.The contract also shows thatyou are responsible for an $85 copayment for each periodontal scaling and root planing per quadrant.Therefore, we decided that the Plan does not have to waive the copaymentfor the complete series of intraoral x-raysand4periodontal scalings and root planings -four or more teeth per quadrantprovided on August 14, 2019. We also decided that the plan does not have to pay for the core buildup, including any pins when required, and application of desensitizing resin for cervical and/or root surface provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit on August 29, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you had a wellness check-up and
should not be billed for the visit. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for Medicare-covered physician services.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows diagnosis
codes for hypothyroidism, hyperlipidemia, fatigue, and overactive bladder in addition to the annual wellness
visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the office visit provided on August 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 5, 2019 by an out of network provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your provider provided medically necessary services to the enrollee and in consideration for the services rendered is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 subsequent nursing facility care provided on July 5, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says there are in-network
providers that can provide 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 pre-approve 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary/rest home visit provided on April 26, 2019.
You asked the Plan to pay for a domiciliary/rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service.
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 a domiciliary/rest home visit provided on April 26, 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 enrollee cannot receive therapy in a lower level
of care due to his ongoing health issues. The IRF is the best option. The Plan denied your request. The Plan
says the enrollee's medical condition appears stable. Submitted clinical documentation indicates that there is no
ongoing treatment of acute or acute on chronic medical conditions. As such, he can be adequately managed in a
lower level of 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee is a male who was admitted on 12/16/2019 for an L1 fracture after a fall.
He was put on a dysphagia diet due to aspiration concerns. On 1/6/19, he underwent kyphoplasty with initial
pain reduction but now with recurrence.
The complexity of the patient'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 patient required the intensity of an IRF stay with close physician or nursing supervision. The patient may
benefit and participate in additional therapy of PT and OT but the patient's functional level and tolerance do 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 preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 38525 provided on June 24, 2019.You asked the Plan to pay forCPT code 38525. You say that the medical records support the billing of CPT code 38525.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 38525.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 38525 is Biopsy or excision of lymph node(s); open, deep axillary node(s).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 CPT code 38525. Our reviewer says that the medical records do not support the billing of CPT code 38525. Our physician reviewer found National Correct Coding Initiative (NCCI) Policy Manual, chapter I states: Physicians must report services correctly. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. Based on the documentation provided, CPT code 38525 is not supported. The record does not contain evidence that a deep axillary lymph node was excised.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 38525 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 38525 provided on June 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive evaluation provided by on October 7, 2019.
You asked the Plan to waive the copayment for the comprehensive evaluation. You say that this was your routine yearly preventive care visit to the gynecologist. You say that this should be covered like your yearly physical to your primary care physician. The Plan denied your request. The Plan says the copayment applied correctly.
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 $45 office visit copayment if services are provided by a specialist. You have been asked to pay a $35 copayment, which is less than the standard copayment for the comprehensive evaluation. The comprehensive evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a gynecologist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the comprehensive evaluation provided by on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on July 31, 2019.
You asked the Plan to waive the copayment for the echocardiography. You say that this was a specialist visit. You say that you should only be charged a $40 copayment for the visit. The Plan denied your request. The Plan says the copayment applied correctly.
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 $50 copayment for all other diagnostic procedures and tests. You have been asked to pay a $50 copayment for the echocardiography. The echocardiography 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 for the echocardiography provided on July 31, 2019.