Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP provided on November 5, 2020.

You asked the Plan to waive the coinsurance for the CPAP device. You say that you do not feel that the CPAP machine is worth the $30 copayment. You say you have never had to pay for your CPAP machine. 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 20% coinsurance for covered items and related supplies.

You have been asked to pay $30 which is 20% of the allowed amount for the CPAP device. The allowed amount is $150. ($150 x 20% = $30). The CPAP device falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the CPAP provided on November 5, 2020.

Please note, our decision is only regarding the November 5, 2020 date of service. Please contact the Plan directly for any questions regarding previous years' billing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on September 16, 2020.
You asked the Plan to pay for the extraction. You say that you need the reimbursement to pay for your bills and food. You say that the Plan is obligated to mail your reimbursements. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed.
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 Plan also has a maximum benefit of $250 every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services combined. The Plan paid $250 for the bone replacement graft provided on September 16, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the extraction provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays
(D0274), topical application of fluoride excluding varnish (D1208), periodontal maintenance (D4910), and four
gingival irrigations (D4921 x4) provided on February 5, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, topical application of fluoride
excluding varnish, periodontal maintenance, and gingival irrigations. You say that you found this dentist in the
Plan's provider directory. The Plan denied your request. The Plan says services rendered by a provider who is
not in-network are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), topical application of fluoride excluding varnish (D1208), periodontal maintenance (D4910), and four gingival irrigations (D4921 x4) provided on February 5, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that time is needed to get the enrollee into the proper facility to continue care. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved, and she is no longer a threat to herself or others.

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. The enrollee does not appear to require inpatient mental health treatment as she is not a danger to herself or others, is not having auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place. It does not appear that the services are reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 8, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you do not know if it is appropriate to be charged the specialist copayment because you were seen by a nurse practitioner. 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 $45 copayment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen at a head and neck specialty office. 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 specialist office visit provided on February 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on March 11, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that the therapist only saw you for five minutes and told you the problem is more severe than what he can do for you. You say that you should not be responsible for the charge when you weren't treated. 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 $30 copayment for each in-network visit for Medicare-covered occupational therapy, physical and/or speech and language therapy visits.
You have been asked to pay a $30 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that an evaluation was performed. 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 physical therapy provided on March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that home health care services are not working
and the enrollee needs more assistance to gain function back. The Plan denied your request. The Plan says the
guidelines for coverage of SNF care have not been met. The Plan says that the enrollee is not medically stable
to transfer to another level of care. The Plan says that the enrollee can safely receive the services needed in the
current hospital setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and tolerated a cervical collar and TLSO. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a moderate assist level with bed mobility and had difficulty following commands. The week prior, the enrollee was at a contact guard assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, however they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: 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 the records provided support the need for care in an IRF. The Plan denied your request. The Plan says the enrollee can receive the care needed at an alternate level.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for peripheral vascular disease and above the knee amputation. The enrollee's medical conditions
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospital services

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this psychiatric care could be provided safely and effectively at a lower 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric services are medically reasonable and necessary. Our physician reviewer found that based upon a review of the provided records, it was expected that this enrollee would improve in a reasonable period of time for the dates in question, as although they did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations, this enrollee did show abnormal behaviors requiring acute treatment. It did appear medically reasonable and necessary to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates initially provided, as although they did not have dangerousness to self or others, the enrollee remained quite psychotic. The health Plan's denial of continued inpatient psychiatric services is inappropriate.

It did appear that active treatment was taking place beyond the date in question. It did appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. This reviewer is unable to find an individualized treatment plan; however, it is alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission, the enrollee does meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 20, 2021 forward, as although this enrollee was not shown to be a danger to herself or others, they were showing abnormal behaviors requiring treatment due to acute threats of safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric hospital services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately managed in another setting and LTACH is the best setting for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan.

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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient psychiatric hospitalization.

You asked the Plan to pre-approve acute inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 acute inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected you would improve in a reasonable period of time as are not showing any signs of danger to yourself or others, you are not having any auditory or visual hallucinations and show no aggressive behaviors. You were compliant with treatment and have had no side effects to medication. It does 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.

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 psychiatric hospitalization have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means acute psychiatric hospitalization is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient psychiatric hospitalization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns provided on March 25, 2021.
You asked the Plan to pay for the crowns. You say that you needed this procedure because your teeth were small and causing food to get stuck in between. You say that you are on a limited income and payment should be considered. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crowns provided on March 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for COVID-19 provided on January 7, 2021.
You asked the Plan to pay for infectious agent detection by nucleic acid. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 infectious agent detection by nucleic acid for COVID-19 provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office or other outpatient visit (99204) provided November 4, 2020.
You asked the Plan to waive the copayment for office or other outpatient visit. You say that you would like this copayment waived as you did not receive the standard of care expected by a medical specialist. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $40 copayment for physician specialist services. You have been asked to pay a $40 copayment for office or other outpatient visit. This service falls within the physician specialist 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 for office or other outpatient visit (99204) provided November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary.
The Plan denied your request. The Plan says your request is not a covered benefit because your records show
that your provider ordered these devices preventatively and your records do not demonstrate that you have
lymphedema or venous insufficiency.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
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, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676).