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

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 at the time of discharge from the hospital you had stabilized medically. You did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. You did not have any parental medication, complex wound care or nutrition given via a feeding tube. You were medically stable without any acute exacerbations of chronic medical problems. Your physical function was at or near your baseline and you could have received further services at a lower level of care. Admission to a SNF for inpatient skilled care was not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Precision Xtra diabetic test strips.

You asked the Plan to pre-approve the Precision Xtra brand test strips. You say that you have been using this brand for some time and wish to continue with it. The Plan denied your request. The Plan says there is no medical reason noted that you cannot use the preferred brands offered by the Plan.

The Plan must follow Medicare rules. Medicare rules say that Plans may restrict enrollees to certain brands for equipment as long as all medically necessary brands are covered. 

In this case, review of medical records shows no documented medical reason that the Plan preferred brands would not be appropriate for you. Therefore, we decided that the Plan does not have to pre-approve Precision Xtra diabetic test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that this is a request for a repeat CT scan of the head. There is no specific clinical rationale provided for the requested CT scan. Artifacts in the posterior fossa are very common and may occur again during a repeat scan. The skull bone creates artifacts and so do the adjacent elements. The request for a repeat CT scan is denied as not medically indicated based on the fact that there is no clinical benefit of a repeat CT scan, as the original had clear images.

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-approve a computed tomography (CT) scan of the head.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 16, 2020.
You asked the Plan to pay for the office visit. You say that you are resubmitting the claim with supporting documentation. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 office visit provided by an out-of-network provider on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scale.
You asked the Plan to pre-approve a scale. You say that the requested item is necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a scale.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 18,
2020.
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 Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid
panel, for symptomatic patients with suspected or documented cardiovascular disease.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation provided is insufficient to establish the medical necessity and reasonableness of the
requested service.
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 pay for laboratory services provided to the enrollee on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is not expected to do three hours of therapy a day, or need an intensive team approach.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 physician reviewer found that the enrollee was admitted to the acute hospital for electrolyte abnormalities and hypotension. Her medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the prostatectomy.

You asked the Plan to waive the copayment for the prostatectomy. You say that this is a doctor caused injury that you shouldn't have to pay for. 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 $275 copayment for each Medicare-covered outpatient surgery at an in-network ambulatory surgical center or outpatient hospital.

You have been asked to pay a $275 copayment for the prostatectomy. The prostatectomy 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 for the prostatectomy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on October 22, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not think it is fair to have this additional charge. 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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. When additional services are provided during an office visit, additional copayments can be applied; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 provider on October 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on September 16, 2020, September 20, 2020 and September 27, 2020.
You asked the Plan to waive the copayment for the ER visits. You say that all the walk-in clinics were closed so you went to the ER. You say that you were informed you wouldn't be billed separately for each visit. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. You have been asked to pay a total of $224.94 for the ER visits.
The ER visits fall within the "Emergency Care" benefit category. The Evidence of Coverage states the ER copayment applies to each visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on September 16, 2020, September 20, 2020 and September 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient visit provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services could have been provided in-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 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 outpatient visit provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for telehealth physician services.
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment due to financial hardship. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $25 copayment for physician telehealth services. 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 $25 copayment charged for telehealth physician services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you paid for your extraction. You say that you do not understand why the plan will not pay for the oral exam. You say that this service is listed as covered. You also say that the provider's office is listed in the guide as your provider for insurance. The Plan denied your request. The Plan says services must be performed by your assigned general dentist. The Plan says that the provider in this case is an oral surgeon.

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 dental service when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 23, 2020.
You asked the Plan to pay for the dental service. You say that you have not received the dental care that you need. You say that you were told that the services would be covered. You also say that you keep getting denials. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The Plan says that the frequency limit has been exceeded.
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 and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 15, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 1, 2020, to July 13, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the type of bill submitted on this claim (324) and HIPPS code (3AHKI) are incorrect. The Plan states a corrected claim is required.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as billed due to the omission of an appropriate type of bill code. The Plan provided guidance on how to correct this claim. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 1, 2020, to July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit for ketamine infusions provided March 2, 2020.
You asked the Plan to pay for the ketamine infusions. You say that please review all attachments and submit this claim for payment. The Plan denied your request. The Plan says this type of therapy is considered experimental, investigational and/or unproven and is not covered by the plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. Based on this information, we decided that Medicare rules for coverage of the ketamine infusions have not been met. Therefore, we decided that the Plan does not have to pay for the office visit for ketamine infusions provided March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection.

You asked the Plan to waive the copayment for the lumbar injection. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

You have been asked to pay a $200 copayment for the lumbar injection. The lumbar injection 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 for the lumbar injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for implantation of biologic implant (e.g., acellular dermal
matrix) for soft tissue reinforcement (e.g., breast, trunk) (List separately in addition to code for primary
procedure) (15777).

You asked the Plan to pay for the outpatient surgical services. You say that please have this claim reconsidered
for additional payment. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon,
or surgical team are not covered for this procedure.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for implantation of biologic implant
(e.g., Acellular dermal matrix) for soft tissue reinforcement (e.g., breast, trunk) (List separately in addition to
code for primary procedure) (15777).