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

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 29,
2018 through July 31, 2018.
You asked the Plan to waive the copayment for the inpatient stay. You submitted your bill for review. You say
that you cannot afford additional bills. 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 $300
copayment per day for days 1-5 for each Medicare-covered hospital stay. Inpatient hospital care starts the day
you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last
inpatient day.
You have been asked to pay a $600 copayment for the inpatient stay. ($300/day x 2 days = $600). The inpatient
stay falls within the "Inpatient hospital 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
for the inpatient stay provided from July 29, 2018 through July 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran observation stay provided  on September 18, 2019.You asked the Plan to waive the copayment foran observation stay. You say that you have never been charged in the past and disagree with the charges.The Plan denied your request. The Plansays 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 $395 copayment for observation services. You have been asked to pay a $395 copayment for an observation stay. An observation stay falls within the outpatient hospital 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 foran observation stay provided  on September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on August 6, 2019
You asked the Plan to pay for outpatient lab tests. You say that you were not aware of the requirement of obtaining prior authorization. You say that you provide these services, ordered by a referring provider, in good faith. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider, is also out-of-network.
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 outpatient lab tests provided on August 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on August 21, 2019.
You asked the Plan to waive the copayment for the podiatry visit. You say that you should not be charged a copayment because you did not go to the provider's office. You say they came to you and that the services were post-operative. 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 $30 copayment for each Medicare-covered office visit for podiatry services. You have been asked to pay a $30 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The record shows you received podiatry services.
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 podiatry visit provided on August 21, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for joint implants to the second and third metatarsal phalangeal joint (MPJ) (28899) provided on June 28, 2019.
You asked the Plan to pay for implants. You say that this service was medically necessary. The Plan denied your request. The Plan says that this service is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 MPJ implants. Our reviewer says that the requested joint implants to the second and third MPJ are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that this patient suffers with osteoarthritis of the second and third MPJ on the right side, necessitating surgical intervention. Joint implantation to the lesser metatarsal phalangeal joints has been utilized for many years. They can be considered the standard of care. In this particular case the joint implants are utilized to repair a malformed and painful body. These implants are utilized to improve the function of the second and third MPJ. They are safe and effective, not mainly for the convenience of the patient or the physician, and appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MPJ implants have been met. Therefore, we decided that the Plan has to pay for joint implants to the second and third metatarsal phalangeal joint (MPJ) (28899) provided on June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetranscatheterimplantation of a wireless pulmonary artery pressor sensor (CardioMEMS) (33289, C2624).You asked the Plan to pre-approvethis service.You say that you are requesting reconsideration of the Plan's denial as the patient's condition could cause health decline and re-hospitalization.The Plan denied your request. The Plan says the records provided do not support medical necessity. An implantable wireless pulmonary artery pressure sensor currently is considered to be experimental and investigational.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 this service. Our reviewer says that the requested service isnot considered medically reasonable and necessary in this case. Our physician reviewer found that in this circumstance,therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore,the efficacy of the CardioMEMS device is uncertain at this time according to leading authoritiesand not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device is considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approvetranscatheter implantation of a wireless pulmonary artery pressor sensor (CardioMEMS) (33289, C2624).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 8, 2019 to June 24, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 8, 2019 to June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202) provided on March 27, 2019 by out-of-network provider.
You asked the Plan to pay for an office visit. You say that the provider was credentialed with the Plan as of March 28, 2018. The provider is in-network with the Plan as of March 15, 2019 prior to the enrollee's services and should be paid as in-network. The Plan denied your request. The Plan says if you need medical care that Medicare requires the Plan to cover and the providers in the network cannot provide this care, you can get this care from an out-of-network provider. Prior Authorization should be obtained from the Plan prior to seeking care. In this situation, if the care is approved, you would pay the same as you would pay if you got the care from a network provider.
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 an office visit (99202) provided on March 27, 2019 by out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee from
September 9, 2019 to September 13, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this was not billed correctly.
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 64595 is "Revision or removal of peripheral or gastric
neurostimulator pulse generator or receiver."
We find that CPT code 64595 is not supported in the medical record. Specifically, this code was submitted
without a code for an allowed procedure. Based on this information, we decided that Medicare rules for
coverage of this code, and the rest of the codes billed, have not been met. Therefore, we decided that the Plan
does not have to pay for outpatient hospital services provided to the enrollee from September 9, 2019 to
September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission to the facility for administration of a study drug.
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee must be admitted to the facility to receive this treatment. The Plan denied your request. The Plan says since this admission is necessary for the clinical trial, Original Medicare would pay for this as a routine cost associated with the trial. The health plan is not responsible for these routine costs.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the inpatient admission as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve inpatient admission to the facility for administration of a study drug.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered to you on September 18, 2019.
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied your request. The Plan says you exceeded the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months. We looked at the file and Medicare rules. The file shows that you previously received an annual wellness visit on April 17, 2019 for which the Plan approved and paid. The annual wellness visit on September 18, 2019 was performed fewer than 12 months from your previously covered annual wellness visit. Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered to you on September 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lipiflow heat treatment procedure (0207T).
You asked the Plan to pre-approve these services. You say that the procedure is medically necessary as the member has dry eye syndrome due to Meibomian gland dysfunction. The Plan denied your request. The Plan says per medical policy, the Lipiflow procedure is considered investigational as there have not been any long term studies demonstrating the safety and efficacy of this provider. Investigational services are not a covered benefit under the enrollee's plan.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence in the medical literature at this time is not sufficient to support the use of the Lipiflow system for the treatment of dry eyes due to Meibomian gland dysfunction. The superiority of this treatment system has not been adequately demonstrated when compared to standard treatment methods. 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 the Lipiflow heat treatment procedure (0207T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 21, 2019.
You asked the Plan to pay for the services. 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 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 medical services provided to the enrollee by an out-of-network provider on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/29/20 for the treatment of acute respiratory distress syndrome related to known idiopathic pulmonary fibrosis. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation and overnight BiPAP, surveillance laboratory studies, electrolyte supplementation, telemetry, prednisone, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Electrocardiogram (ECG) interpretation (93010) provided March 13, 2019.
You asked the Plan to pay for the ECG interpretation. You say that the services were billed correctly. The Plan denied your request. The Plan says the record provided does not support code 93010.
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 93010 is Electrocardiogram Report. We find that CPT code 93010 is not supported in the medical record. Specifically, only a print out of the ECG was provided. There were no physician notes provided that show interpretation, diagnosis or treatment of any condition. The record does not support the ECG Interpretation as a separate service billed. Based on this information, we decided that Medicare rules for coverage of the ECG interpretation have not been met. Therefore, we decided that the Plan does not have to pay for Electrocardiogram (ECG) interpretation (93010) provided March 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ulcer boats.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve ulcer boats.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial maxillary denture (D521) and a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you had to have front teeth pulled. You say that you will need partial dentures as a result. You also say that you will not be able to eat without them. The Plan denied your request. The Plan says the partial dentures are not listed as covered services. 
 
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 partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D521) and a partial mandibular denture (D5214).