Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 13, 2019 to December 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was readmitted to the SNF after an acute hospitalization for dementia with behavioral issues. He received oral medications and had stable vital signs. He received physical, occupational, and speech therapy. By the dates in question he had progressed to stand-by to contact guard assist with functional mobility, including gait to 250 feet with a rolling walker. He had no skilled nursing needs. He had skilled therapy needs but did not require skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 13, 2019 to December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the specialist services rendered on January
30, 2019 to May 29, 2019.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $975 yearly deductible for your covered medical services and a $50
copayment after you pay your $975 deductible for out-of-network physician specialist services.
Review of the file shows that you received specialist services on January 30, 2019 and February 26, 2019.
These services fall within the out-of-network physician specialist services benefit category. The Plan has
followed Medicare rules by clearly disclosing in the contract that there is $975 yearly deductible for your
covered medical services. This cost sharing is a contractual obligation that had not been met at the time these
services were received on January 30, 2019 and February 26, 2019.
The file shows that you received specialist services on May 10, 2019 and May 29, 2019. You have been asked
to pay a $50 copayment per date of service for these services, for a total of $100. These services fall within the
out-of-network physician specialist services benefit category. This means that you have been asked to pay the
correct amount for these services based on the contract with the Plan. This cost sharing is a contractual
obligation that you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the cost sharing for the specialist services rendered
on January 30, 2019 to May 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings. The Plan
denied your request. The Plan says they are a non-reusable supply item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
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 based on the enrollee's ongoing and
complicated medical needs, his providers have determined that he is stable and suitable for transfer to an
LTACH. You say that the enrollee cannot be adequately managed in his current condition at a skilled nursing
facility. You say that the enrollee requires prolonged hospitalization with daily physician management and the
intensive skilled services that are offered in the LTACH setting. The Plan denied your request. The Plan says
the enrollee is not medically stable and needs to stay in the hospital until he is better. The Plan says that the
guidelines for coverage of LTACH care have not been met.
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 is currently undergoing treatment at an acute care hospital (ACH),
having initially presented with altered mental status and infected toes. The enrollee suffered a cardiac arrest and
was intubated/ventilated. The enrollee has since been extubated and is no longer on a ventilator. The enrollee
continues to be managed for cardiac arrhythmias, renal failure, GI bleeding, gangrenous digits and pressure
sores. There is no evidence that the enrollee requires services that are not currently available. The enrollee
appears to be at high risk for repeat decompensation. There is no advantage in transferring the enrollee to the
LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on October 22, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 physical therapy services provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laser (Femtosecond) portion of cataract surgery
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no additional payment for the use of a laser during cataract surgery.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found femtosecond LASER-assisted portion of cataract surgery for the purpose of corneal protection is not medically necessary based on evidence in the medical literature. You had decreased vision related to cataract. This was supported by the visual acuity measurement of 20/30 in the right eye. Medicare coverage criteria were met for the services of cataract extraction according to typical guidelines for medical necessity, but the addition of femtosecond LASER surgery is not medically necessary, even in the setting of Fuchs corneal dystrophy. The available medical literature demonstrates mixed evidence for the use of femtosecond laser in the setting of Fuchs. The largest retrospective analysis (over 200 patients) shows no benefit compared to standard surgical technique. Prospective studies show average decrease in endothelial cell loss after 12 months with femtosecond laser assist as compared to standard technique, however, relatively few patients are involved (31 eyes) and there is no evidence that the difference would translate to decrease in need for future corneal transplant. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the laser (Femtosecond) portion of cataract surgery
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram (77067) provided on January 23, 2020.
You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 screening mammogram (77067) provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for renewal for gym membership purchased on December 30,
2019.
You asked the Plan to pay for the gym membership. You say that you paid your 2020 membership on
December 30, 2019. Please reimburse you for this membership under your wellness coverage. The Plan denied
your request. The Plan says the annual maximum benefit limit has been reached.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits
only once per year.
The Plan's rules for coverage of gym benefits have not been met because the benefit is based on the date the
service was purchased or obtained. The date of service for this benefit is the date you make payment. For
example, if you pay on December 15 for a gym membership that starts January 1, December 15 is the date of
service. Records show you purchased your gym membership on January 4, 2019 and the plan reimbursed $240
on January 30, 2019. You purchased your gym membership renewal on December 30, 2019. Therefore, we
decided that the Plan does not have to pay for renewal for gym membership purchased on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided on October 4, 2019 by an out of
network provider.
You asked the Plan to pay for the CPAP rental. You say that the CPAP is required for a lifetime but you moved
and changed plans. The Plan denied your request. The Plan says the provider is not in network and you did not
request prior approval.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the CPAP rental provided on October 4, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no dental benefits for routine care from the plan, and there is no dental rider.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a dental extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on November 6,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99152 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by physician also
performing a procedure, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records show that
moderate sedation services beyond 15 minutes were performed and a more appropriate code should have been
billed for the services beyond the first initial 15 minutes. 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 for the moderate sedation services rendered on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed with the CLIA number.
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the claim was not billed with the required CLIA number. 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 for the laboratory services rendered on August 8, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.
You asked the Plan to pre-approve these services. You say that the treatment has been helping. 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 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the submitted documentation does not contain any physical therapy or aquatic therapy records for review. There is no documentation to show that you are responding to the exercise program. The requested therapy is not generally accepted as specific and effective therapy for your condition. The records do not show that the unique skills of a professional therapist are required to safely and effectively provide treatment. After 26 visits, further aquatic therapy is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology consultation.
You asked the Plan to pre-approve the requested consultation. You say that you have a problem with your skin, and need to be seen by dermatology. The Plan denied your request. The Plan says your primary care physician (PCP) should be able to follow-up with treatment.
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 requested consultation. Our physician reviewer found that the records submitted from the previous dermatology evaluation on July 22, 2019, showed that you have benign dark areas of skin on your chin that were treated with Hydroquinone 4% topical cream and Hydrocortisone 1% cream. You also had some broken blood vessels, benign spots and areas of sun damage. The enrollee's PCP can follow her skin conditions. Therefore, a dermatology consult is not medically reasonable or 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 the requested consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a dermatology consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided on December 4, 2019 by an out of
network provider.
You asked the Plan to pay for the CPAP rental. You say that the CPAP is required for a lifetime but you moved
and changed plans. The Plan denied your request. The Plan says the provider is not in network and you did not
request prior approval.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the CPAP rental provided on December 4, 2019 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from
August 20, 2019 to September 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
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 these services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the submitted records show that you received
oral medications and had stable vital signs. You received physical and occupational therapy. By the dates in
question, you were independent to needing supervision with functional mobility, including walking to 400 feet.
You needed varied assistance with activities of daily living. You had no skilled nursing needs. You had skilled
therapy needs but did not require skilled therapy on a daily basis. As a practical matter, you did not require the
necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) services rendered from August 20, 2019 to September 5,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for periodic oral exam (D0120) the cleaning
(D1110) intraoral-periapical x-rays (D0220) provided on November 15, 2019.
You asked the Plan to waive the copayment for the dental services. You say that you believe that the services
should be fully covered by the plan. The Plan denied your request. The Plan says this claim was processed
correctly with the correct coinsurance applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that the $100 deductible
needs to be satisfied then the member is responsible for 20% for preventive dental services. for Dental services.
You have been asked to pay $23 for the dental services. The services fall within the Dental 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. Therefore, we
decided that the Plan does not have to waive the copayment for periodic oral exam (D0120) the cleaning
(D1110) intraoral-periapical x-rays (D0220) provided on November 15, 2019.