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

We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that LTACH services are not medically necessary for the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded a complete case file, including medical records for your appeal request. Without this documentation we are unable to substantiate the Plan's denial. Therefore, we decided that the Plan has to pre-approve long term acute care hospital (LTACH) services for the enrollee.
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 x-ray, spine, lumbosacral (72100) outpatient office visit (99214) provided October 22, 2020.
You asked the Plan to pay for the outpatient office visit. You say that the records provided should support necessity of the services in dispute. The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the x-ray, spine, lumbosacral (72100) outpatient office visit (99214) provided October 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found it is not medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". This enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until October 16, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on March 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the spacer device. Open laminectomy remains the gold standard for spinal stenosis decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the clinical information provided supports the need for SNF care. The Plan denied your request. The Plan says the records do not support that the services needed are unable to be provided in the current inpatient rehabilitation facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee received and physical therapy, speech therapy, occupational therapy in the acute hospital. The enrollee was at a moderate assist level for functional mobility including gait in the parallel bars to 8 feet. the enrollee required varying assist with activities of daily living. The enrollee tolerated a pureed diet and thin liquids. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care rendered from September 2, 2020 to September 3, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services were 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 correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 pneumonia. She presented to the emergency department (ED) with shortness of breath for 24 hours, nasal congestion for one week, cough with yellow mucous, and poor appetite. The records show that, at the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 for the acute inpatient hospital care rendered from September 2, 2020 to September 3, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization services provided from May 21, 2020,
to May 23, 2020.
You asked the Plan to pay for the post stabilization 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.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post stabilization services. Our reviewer
says that the documentation does not support that the services rendered were medically reasonable or
necessary. Our physician reviewer found the documentation shows that the enrollee was in no acute distress,
alert and oriented, and hemodynamically stable for safe ambulance transport with monitoring to a to a plan
facility. There was no documentation provided necessitating post- stabilization care services at the nonparticipating
facility after 5:33 pm. The review has determined that the treating physician did not document (in
the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of
service. Therefore, the enrollee did not meet criteria for the services rendered.
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 post stabilization services have not been met. Therefore, we decided that the
Plan does not have to pay for the post stabilization services provided from May 21, 2020, to May 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion system.
You asked the Plan to pre-approve a Vertiflex Superion system. You say that Medicare has been known to cover the interspinous decompression spacer procedure. You say that the enrollee has suffered from his condition for more than 3 years and it has greatly impacted his quality of life. You say that the enrollee has failed conservative treatments. You say that the requested treatment is considered safe and effective, as supported by its clinical benefits to patients, continued medical professional adopting, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective.
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 a Vertiflex Superion system. Our reviewer says that a Vertiflex Superion system is not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard for spinal stenosis decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory disorder genetic testing panel provided on August 17, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is considered non-covered screening.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology screening services are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for respiratory disorder genetic testing panel provided on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from October 14, 2020 to October 22, 2020. You asked the Plan to waive the copay for the inpatient hospital services. You say that you should not have to pay these charges because you were forced to stay in the hospital because of accident by your physician. The Plan denied your request. The Plan says that you were charged 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 $310 copay per day, per stay for days 1-7 of inpatient hospital care. You have been asked to pay a $2,021.50 copay for the inpatient hospital services. The inpatient hospital services fall within the days 1-7 of inpatient hospital care benefit category. This means that you have been asked to pay less than 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 for the inpatient hospital services provided from October 14, 2020 to October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral radiographic images (D0220), porcelain/ceramic crown (D2740) and core buildup procedure (D2950) provided on November 2, 2020.
You asked the Plan to pay for the dental services. You say that you were not aware that you did not have coverage for these services. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral radiographic images (D0220), porcelain/ceramic crown (D2740) and core buildup procedure (D2950) provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 3, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you called 3 times about this issue. You say that you got a bill, and nobody will help you. 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 $110 copayment for each Medicare-covered radiological diagnostic service from an in-network provider. You have been asked to pay $88.54, which is less than the standard $110 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The records show you were only charged a copayment for the ultrasound. 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 ultrasound provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the visual field examination (92083), the computerized ophthalmic diagnostic imaging (92134), and the ophthalmological medical examination and evaluation (92004) rendered by the out of network (OON) provider on June 5, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the visual field examination (92083), the computerized ophthalmic diagnostic imaging (92134), and the ophthalmological medical examination and evaluation (92004) rendered by the out of network (OON) provider on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital on October 5, 2020.
You asked the Plan to waive the copayment for lab work. You say that you had your annual wellness visit and this should be covered. The Plan denied your request. The Plan says the correct copayment has been 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 you must pay a $50 copayment for outpatient diagnostic tests/lab services/outpatient hospital. You have been asked to pay $20.83 which is less than your copayment amount of $50 for lab work. When additional services are provided during an annual wellness exam, like lab work, additional copayments are provided. Lab work falls within the outpatient diagnostic tests/lab services/outpatient hospital 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 lab work provided by a participating hospital on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on December 20, 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 01830 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 01830 is anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified. We find that CPT code 01830 is not supported in the medical record. Specifically, there is no documentation of anesthesia for open or surgical arthroscopic/endoscopic procedures on the distal radius, distal ulna, wrist, or hand joints. 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 anesthesia services rendered on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a push-rim power assist for a manual wheelchair (E0986) provided on September 30, 2020, by an OON provider.
You asked the Plan to pay for a push-rim power assist for a manual wheelchair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 had network providers available who could have provided 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 a push-rim power assist for a manual wheelchair (E0986) provided on September 30, 2020, by an OON provider.