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

We decided that the Plan does not have to pre-approve an acute inpatient mental health admission.
You asked the Plan to pre-approve this service. You say that an acute inpatient mental health admission is medically necessary. The Plan denied your request. The Plan says an acute inpatient mental health admission 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 this service. Our reviewer says that the enrollee does not meet criteria for coverage of inpatient psychiatric services. Our physician reviewer found that 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 as the enrollee does not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations.
This enrollee does not appear to require inpatient mental health treatment as he is not a danger to himself or others and is cooperative and compliant. The requested services are not reasonably expected to improve the enrollee's condition or are for the purpose of a diagnosis. It is not expected this enrollee would improve in a reasonable period of time as he does not have dangerousness to self or others, auditory or visual hallucinations and was not showing any behavioral issues or withdrawal symptoms.
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 an acute inpatient mental health admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin three surfaces, posterior, tooth 20 (D2393) provided February 24, 2020.
You asked the Plan to pay for the dental services. You say that you were told by plan representatives that these procedures were covered. Furthermore, if your plan has an annual coverage maximum of $1000, any dental procedures your dentist deems necessary should be covered up to that maximum. The Plan denied your request. The Plan says per the plan benefits this service is 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. The health plan contract specifically says that resin based composite restoration is covered for the anterior teeth. This service is for the posterior teeth which is not covered. 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 resin three surfaces, posterior, tooth 20 (D2393) provided February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and portable oxygen system provided from November 3, 2019 through March 3, 2020. You asked the Plan to waive the coinsurance for the oxygen concentrator and portable oxygen system. You say that you didn't ask for the oxygen and you didn't use it. You say that you shouldn't have to pay for this. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay a total of $158.15 for the oxygen concentrator and portable oxygen system. The oxygen concentrator and portable oxygen system fall within the "Durable medical equipment (DME) and related supplies" benefit category. The records show that you received the equipment. 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 oxygen concentrator and portable oxygen system provided from November 3, 2019 through March 3, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Foundation One testing provided on February 18, 2020.You asked the Plan to pay for genetic testing. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.The Plan follows Medicare rules. Medicare rules say that next generation sequencing tests are covered by Medicare when they meet the above listed criteria.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 genetic testing. Our reviewer says that this testing meets the Medicare criteria for coverage. Our physician reviewer found the enrollee has metastatic, advanced stage IV cancer. There is no documentation that the enrollee has been previously testing using the same next generation sequencing method for the same primary diagnosis of cancer. Further cancer treatment has been recommended We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pay for Foundation One testing provided on February 18, 2020.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of L4-5 and L5-S1.
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the above criteria are met. 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 RFA. Our reviewer says that the requested RFA is not medically reasonable and necessary. Our physician reviewer found that the LCD requirement is greater than 80% pain relief from both diagnostic sets. This is not documented in the progress notes as only 33% pain relief was achieved on the second set. Therefore, the tests are negative and the request is not medically reasonable or 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 the RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of L4-5 and L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on March 16, 2020.
You asked the Plan to waive the copayment for the EKG. You say that your specialist office visit has a $40 copayment and no one said that a diagnostic test would be an additional copayment. 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 $5 copayment for in-network diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $5 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the EKG provided on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for full mouth debridement (D4355) provided November 4, 2019.
You asked the Plan to pay for the dental services. You say that the records should support the necessity of the service. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 full mouth debridement (D4355) provided November 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your
benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator (99190) provided January 15, 2020.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99190 is Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, this code is excluded from payment per the Physician Fee Schedule. 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 assembly and operation of pump with oxygenator (99190) provided January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 26, 2020.You asked the Plan to pay for the physician's services. 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 physician's services provided on February 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on March 8, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that the enrollee should not be responsible for the copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per one-way trip by ground or air ambulance. The enrollee has been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on March 8, 2019.
Your complaint that the nursing facility had not detected the enrollee's broken hip is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the health club membership purchased from January 1, 2019 through December 31, 2019.
You asked the Plan to reimburse for the health club membership. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the form was mailed in early February, 2020 and received by the Plan on February 10, 2020 and it was indicated that the claim should have been in no later than January 31, 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Review of the file show that you the reimbursement form for your health club membership was mailed in early February, 2020 and received by the Plan on February 10, 2020 and it was indicated that the claim should have been in no later than January 31, 2020. Your EOC states, member requests for reimbursement of qualified membership dues may be submitted monthly but must be received no later than 31 days following the end of plan year. Therefore, we decided that the Plan does not have to reimburse for the health club membership purchased from January 1, 2019 through December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 10, 2020 through February 11, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. 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 pay for the acute inpatient hospital care provided from February 10, 2020 through February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 14, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 physician's services provided on May 14, 2019.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says you can utilize any ongoing physical and occupational therapy needs through outpatient benefits. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled therapy services. The specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist are not needed in this case. Based on the medical records provided you do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the long-term care facility on a part time basis appears appropriate in this case. 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has competed the course of care in the hospital. The Plan says that the enrollee still needs surgery to help remove the infection and that she can stay in the hospital to finish treatments.
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 short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The short-term acute care hospital can provide for all the patient's present inpatient care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and the ultrasound provided on January 9, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram and the ultrasound. You say that you should not be responsible for the copayment because the this was a follow up to your mammogram in December 2019. You say you would not have had the service done if you had known you would be charged. 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 $100 copayment for each covered x-ray in the outpatient department of a network hospital or facility. You have been asked to pay a total of $100 copayment for the diagnostic mammogram and the ultrasound. The diagnostic mammogram and the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the diagnostic mammogram and the ultrasound provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 17, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on June 17, 2019.