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

We decided that the Plan does not have to pay for the post stabilization services provided from August 9, 2020 to August 15, 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 enrollee presented to the hospital with shortness of breath. The documentation shows that the cardiologist evaluated the enrollee and noted the enrollee's presenting symptoms had resolved. The enrollee had stable vital signs and oxygen saturation on 3 liters of oxygen per nasal canula. The post-stabilization care services after 3:50 pm on August 10, 2020 were not medically necessary or reasonable. The review indicates 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. 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 August 9, 2020 to August 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 30, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee needs to stay in the hospital until you are better.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not meet prior authorization requirements.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on November 19, 2020.
You asked the Plan to pay for the dental services. You say that you go to your dentist every 4 months. You say that you were developing gum disease. You also say that you hope that your insurance will take care of their part of this bill since your visits have been for preventive reasons. The Plan denied your request. The Plan says 2 oral exams and cleanings per calendar year are covered. The Plan also says that the frequency limit for these services have 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, the frequency limits for these services have been exceeded. The record shows that the Plan paid for cleanings and oral exams that you received on February 6, 2020, and June 25, 2020. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided a participating provider on July 27, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you should not have to pay this high of a copayment. 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 $200 copayment for outpatient surgery/outpatient hospital facility visit. You have been asked to pay a $200 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility visit 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 an injection provided by a participating provider on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and cleaning (D1110) provided on December 18, 2020.
You asked the Plan to pay for the dental services. You say that you are covered for oral exams and cleanings every 6 months. You also say that your dental appointments were 6 months apart, to your knowledge. The Plan denied your request. The Plan says that oral exams and cleanings are covered once every 6 months. The Plan also says that the frequency limit for these services have been exceeded.
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. We find that the oral exam and prophylaxis that you received on December 18, 2020 does not exceed the 6-month frequency limit. The record shows that the last oral exam and cleaning that you received were on June 17, 2020, 6 months before. Therefore, we decided that the Plan has to pay for the oral exam (D0120) and cleaning (D1110) provided on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerecis Omega 3 and associated application of the product as defined by codes 15275, 15271, Q4158. You asked the Plan to pre-approve wound care. You say that the enrollee needs the wound care. The Plan denied your request. The Plan says the denial was appropriate given the clinical scenario and guidance presented.
The Plan must follow Medicare rules. Medicare rules say that to receive specialized wound care, the wound must be non-responsive to treatment and at least one square centimeter in size. We looked at the file and Medicare rules. From February 22, 2021 to March 23, 2021 the enrollee's wound has gotten smaller. It is not at least 1 square centimeter in size. Based on this information, we decided that Medicare rules for coverage of wound care have not been met. Therefore, we decided that the Plan does not have to pre-approve Kerecis Omega 3 and associated application of the product as defined by codes 15275, 15271, Q4158.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient hospital services.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the procedure is currently approved as an ambulatory procedure.
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 pre-approve acute inpatient hospital care. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is undergoing a planned total shoulder arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and two prophylaxes
provided on February 26, 2020, and June 25, 2020, by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxes. You say that the statement
in your EOC assured you that everything would be covered both in-network and OON. The Plan denied your
request. The Plan says these services were rendered by an OON provider. The Plan also says that the total
liability amount of $142.00 was applied correctly.
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, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation and two prophylaxes provided on February 26, 2020, and June 25, 2020, by
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 30, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you feel that the office visit should be considered an annual wellness visit. The Plan denied your request. The Plan says 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 $20 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness visit provided on September 30, 2020. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuvasive AttraX allograft (bone marrow aspirate) procedure.
You asked the Plan to pre-approve Nuvasive AttraX allograft. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this procedure is helpful for the enrollee's condition.
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 Nuvasive AttraX allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Nuvasive AttraX allograft procedure remains experimental. Bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of the grafting materials. Iliac crest autograft remains the gold standard for grafting in spine surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nuvasive AttraX allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Nuvasive AttraX allograft (bone marrow aspirate) procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound provided on July 20, 2020.
You asked the Plan to waive the deductible for an ultrasound. You say that you disagree with the charges because you feel that you should only owe an office copayment. The Plan denied your request. The Plan says 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. Your contract with the Plan says that there is a $250 deductible for outpatient hospital services. You received an ultrasound on July 20, 2020. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $162.16. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on July 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound provided on July 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)>
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs. The enrollee required contact guard assistance with functional mobility including walking to 150 feet with a rolling walker. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-sharing for an eye examination provided on August 24, 2020.
You asked the Plan to reduce the cost-sharing for eye exam. You say that your eye exam copayment should only be $15. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $45 copayment for eye exam. You have been asked to pay $45 copayment for eye exam. eye exam falls within the Vision 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 reduce the cost-sharing for an eye examination provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services coded 11043, 97598, and 97597 and the fasciotomy services coded 28008 provided from September 19, 2019 to September 26, 2019.
You asked the Plan to pay for the debridement services and the fasciotomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes 11043, 97598, 97597, and 28008 are not supported in the medical record. Specifically, the documentation submitted did not include a detailed procedure note for the billed date of service; therefore, code 11043 cannot be verified. The documentation submitted did not include documentation of total wound surface area; each additional 20 sq cm, or part thereof; therefore, code 97598 cannot be verified. The documentation submitted did not include documentation of total wound surface area; first 10 sq cm or less; therefore, code 97597 cannot be verified. The documentation submitted did not indicate that decompression fasciotomy of lateral and medical compartment of lower leg was performed; therefore, code 28008 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the debridement services and the fasciotomy services have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services coded 11043, 97598, and 97597 and the fasciotomy services coded 28008 provided from September 19, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee does not inject insulin three or more times per day and does not test blood sugar levels four or more times daily. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on June 15, 2020, to October 5, 2020. You asked the Plan to waive the copayment for a skilled nursing stay. You say that this stay did not help with your recovery. 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 $0 copayment per day for days 1-20. There is a $75 copayment per day for days 21-100 for skilled nursing facility. You have been asked to pay a $0 copayment per day for days 1-20. There is a $75 copayment per day for days 21-100 for a skilled nursing stay. A skilled nursing stay falls within the skilled nursing facility 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 a skilled nursing stay provided by a participating provider on June 15, 2020, to October 5, 2020.