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

We decided that the Plan does not have to pay for the skilled nursing facility care provided from August 29, 2019 to September 22, 2019.
You asked the Plan to pay for the skilled nursing facility care received from August 29, 2019 to September 22, 2019. The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility care provided from August 29, 2019 to September 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin filling on tooth #25 provided on October 8, 2019.
You asked the Plan to pay for the resin filling. You say that this procedure was for replacing an old front tooth filling which had fallen out. The Plan denied your request. The Plan says amalgam and composite resin restorations are payable to the same dentist or dental office once within a 24 month period, regardless of the number or combination of restorations placed on surface.
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, resin and amalgam fillings are limited to once every 24 months per tooth. The record shows that you received a resin filling on tooth #25 on July 19, 2018 and your resin and amalgam fillings benefit for tooth #25 is now exhausted. Therefore, we decided that the Plan does not have to pay for the resin filling on tooth #25 provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on June 24, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says that hearing aids not purchased through a certain practice are not a covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays for hearing aids ordered directly from one practice. We looked at the file and the Plan's rules. The file indicates you did not receive the hearing aids through this one practice. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on June 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 15, 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 you feel that IRF care is the best option for your recovery. The Plan denied your request. The Plan says you are medically stable and do not require intensive therapy.
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 member is 78 years old with history of hypertension and TIA, admitted following a mechanical fall and hip fracture warranting operative intervention. Current post-operative care includes management of pain, and Norco provides adequate analgesia. The member is able to walk 80 feet and is mostly minimal assist for ADL's and transfers. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is mostly minimal assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the home health visits provided from October1, 2019 to October 8, 2019.You asked the Plan to waive the deductible for the home health visits. You say that you cannot afford the $750 deductible. 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. Your contract with the Plan says that there is a $750 deductible that applies towards home health visits. The home health visits you asked the Plan to waive the deductible for falls within the "Home health agency care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards home health services. This cost sharing is a contractual obligation that had not been met at the time the home health visits were received on October 1, 2019 to October 8, 2019. Therefore, we decided that the Plan does not have to waive the deductible forhome health visits provided from October1, 2019 to October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 usesthe appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cataract surgeries provided on August 14, 2019 and August 28, 2019.You asked the Plan to waive the copayment forthe cataract surgeries. You say that you had surgery on your left eye on August 14, 2019 and the same procedure on your right eye onAugust 28, 2019. You say you should only have to pay one copayment for both claims. 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 $250 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $250 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe cataract surgeries provided on August 14, 2019 and August 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 8, 2019 through August 31, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were at the SNF facility after your previous surgery. You say that you were unaware of the dates and lengths of time spent in the hospital and rehabilitation facility. 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 $0 copayment for days 1-20 and a $100 copayment per day for days 21-100, per benefit period at an in-network provider. You have been asked to pay a $2,300 copayment for the SNF stay. ($100/day x 23 days = $2,300). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The records show that there has been less than 60 days since your previous SNF stay. 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 SNF stay provided from August 8, 2019 through August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.You asked the Plan to pre-approve these services. You say that you have worsening memory deficits and were not satisfied with the previous in-network neurologist.The Plan denied your request. The Plan says the services are available from network providers.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 care that cannot be provided by network providers.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 that you have not previously seen. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the cataract surgery provided on August 21, 2019.
You asked the Plan to waive the copayment the cataract surgery. You say that you were told by the provider that you received a prior authorization and that the service would be covered. You say you are being charged 100% of the allowed amount. 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 $325 copayment for each Medicare-covered ambulatory surgical center visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the cataract surgery.
You have been asked to pay $230.77 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the cataract surgery provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required on tooth #2, porcelain or ceramic retainer crowns for tooth #'s 2 and 3, and a pontic.You asked the Plan to pre-approve the core buildup, porcelain or ceramic retainer crowns, and pontic. You say that you are unable to get dentures because of a nerve related condition with tremors. You also say that you need the bridge because you are only able to eat on one side of your mouth.The Plan denied your request. The Plan says core buildup is not a covered service. The Plan also says that the abutment tooth #'s 2 and 4 appear to have significant bone loss and/or decay, indicating that they do not have a good long term prognosis.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. The Plan covers the porcelain or ceramic retainer crowns and pontic when the services are medically necessary and reasonable. 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 porcelain or ceramic retainer crowns and pontic. Our reviewer says that the services are not medically necessary. Our physician reviewer found given the severe periodontal disease that has affected tooth #2 which resulted in extensive bone loss, it would not be considered an adequate abutment tooth for the proposed bridge from tooth #'s 2 to 4. Our reviewer also found that the core buildup is a dependent service, and as the primary service of the bridge is found not to be medically necessary due to a lack of adequate bone support the dependent service of the buildup is also not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the porcelain or ceramic retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approvea core buildup, including any pins when required on tooth #2, porcelain or ceramic retainer crowns for tooth #'s 2 and 3, and a pontic.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an oncology gene expression profile provided on August 9, 2019.
You asked the Plan to pay for the oncology gene expression profile. The Plan denied your request. The Plan says that 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 an oncology gene expression profile provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on August 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that you did not know you needed prior authorization for out-of-network providers. The Plan denied your request. The Plan says no prior authorization was obtained for 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 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 wound care provided on August 13, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on April 17, 2019.
You asked the Plan to pay for the initial hospital care. You say that the services that were provided to the enrollee were emergent. The Plan denied your request. The Plan says during the election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on April 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care provided beyond February 10, 2020.
You asked the Plan to pre-approve the continued inpatient care. You say that the enrollee cannot be discharged to the home so he must remain in the inpatient setting. The Plan denied your request. The Plan says the enrollee no longer requires an inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient care. Our reviewer says that the documentation does not support that ongoing inpatient mental health services are medically necessary. Our physician reviewer found this 69-year-old male was admitted to the acute inpatient psychiatric hospitalization on February 5, 2020 with major Neurocognitive Disorder with Behavioral Disturbance Most Likely Due To Vascular Illness and Major Depressive Disorder, Single Episode. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no abnormal behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. 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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care provided beyond February 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an intravascular vena cava filter (37193-52) provided on September 11, 2019.
You asked the Plan to pay for the procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim should have been reported with modifier 53 as appropriate to the circumstances or the service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 procedure. Our reviewer says that 37193-52 does not meet criteria for billing or reimbursement consideration. Our physician reviewer found by definition, modifier 52 indicates reduced services. Modifier 53 is used to indicate a discontinued procedure. In this case, multiple attempts to retrieve the IVC filter were unsuccessful, and the procedure was terminated. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pay for the removal of an intravascular vena cava filter (37193-52) provided on September 11, 2019.