Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical excision of a foot tumor. You asked the Plan to pre-approve foot surgery. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that alternative treatment were attempted, or the functional limitations caused by this 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 foot surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no current documentation relative to the presence of a soft tissue tumor. There is evidence of a bony prominence but no follow-up to demonstrate failure of conservative treatment. Therefore, this request is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of foot surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical excision of a foot tumor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 9, 2019.
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 procedure code 99232 is not supported.
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 99232 is Level 2 subsequent hospital care for evaluation and management of patient. We find that CPT code 99232 is not supported in the medical record. Specifically, the records show that the enrollee was not under inpatient status for the date of service at issue. 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 pay for the subsequent hospital care rendered on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) therefore, the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that Medicare may cover lab testing when ordered by a treating provider. We looked at the file and Medicare rules. The submitted documentation does not include a copy of an order from the treating provider in this case. As such, the Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the level of care and services that Select Specialty Hospital provides is the same level of inpatient care that the enrollee is currently receiving.
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 currently undergoing treatment at an ACH for chronic respiratory failure. The enrollee has a tracheotomy and receives nighttime ventilator support. The enrollee is not expected to be fully liberated from ventilator support or to be decannulated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lightweight wheelchair and leg rests provided on November 13, 2019 by an in-network provider. You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a lightweight wheelchair and leg rests provided on November 13, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 lightweight wheelchair and leg rests provided on November 13, 2019 by an in-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits provided from March 5,
2019 through October 11, 2019.
You asked the Plan to waive the cost share for the office visits. You say that you were informed the provider
was in-network. You say that you didn't know you would owe for using an in-network provider. The Plan
denied your request. The Plan says the cost share applied correctly.
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 your deductible is $200. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Your contract with the Plan says that after you
pay your $200 deductible, you pay 20% coinsurance for out-of-network primary care physician services.
The item or service you asked the Plan to waive the cost share for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $200 deductible applies to out-of-network primary care physician services.
This cost sharing is a contractual obligation that had not been met at the time the office visits were received
from March 5, 2019 to October 11, 2019.
Since your $200 deductible was met, you have also been asked to pay 20% coinsurance for the out-of-network
office visit provided on March 5, 2019 and October 11, 2019. 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 cost share
for the office visits provided from March 5, 2019 through October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheters rendered on September 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that a supplier must have an order from the treating
physician before dispensing any DMEPOS item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the supplies. 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 pay for the catheters rendered on September 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on November 3, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that you believe this amount is excessive and ambulance rides should be covered by insurance. You say you are retired and have limited income and savings. 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 $260 copayment for each one-way trip for Medicare-covered ambulance benefits. You have been asked to pay a $260 copayment for the ambulance ride. the ambulance ride falls within the "Ambulance 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 forthe ambulance ride provided on November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
You asked the Plan to pre-approve the seat lift mechanism. You say that the seat lift is medically necessary.
The Plan denied your request. The Plan says rules of coverage were not met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above 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 seat lift mechanism. Our reviewer
says that the seat lift is not medically necessary in this case. Our physician reviewer found the documentation
does not include imaging studies revealing severe arthritis of the hip or knee. The patient does not have a
severe neuromuscular disease. The seat lift mechanism is not indicated in the treating practitioner's course of
treatment and prescribed to improve, or stop, deterioration of the patient's condition. Although the patient is
ambulatory, the documentation does not reveal the patient is completely unable to stand up from a regular
armchair or any chair in the home.
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 seat lift mechanism have not been met. Therefore, we decided that the Plan
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment (97810) with provider.You asked the Plan to pre-approve these services. You say that you are requesting acupuncture treatment as you have had lower back problems for several years.The Plan denied your request. The Plan says that your request to receive services by provider does not meet Medicare criteria for coverage of acupuncture treatment. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of acupuncture treatment have not been met. Specifically, the acupuncturist requested to provide these services,is not an auxiliary personnel furnishing acupuncture under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist as she has her own private practiceand is self-employed.Therefore, we decided that the Plan does not have to pre-approve the acupuncture treatment (97810).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 29, 2019 to September 27, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stayat a SNF.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 29, 2019 to September 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781) and deluxe frame (V2020) provided on July 15, 2019 by an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that you used this provider before and are satisfied with the services. The Plan denied your request. The Plan says the services were not preauthorized.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Review of the file shows that the service requested due to not requesting a pre-authorization. Therefore, we decided that the Plan does not have to pay for progressive lens (V2781) and deluxe frame (V2020) provided on July 15, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMedtronic Guardian sensors.You asked the Plan to pre-approvesensors for use with an interstitial continuous glucose monitor (A9276). You say that you feel more safe and confident with your health when using the sensors with your pump.The Plan denied your request. The Plan says supplies used with a non-therapeutic CGMs are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor. We looked at the file and Medicare rules. We find that CPT code A9276 is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of sensors for an interstitial continuous glucose monitoring system have not been met.Therefore, we decided that the Plan does not have to pre-approveMedtronic Guardian sensors
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these were necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided on December 17, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you had to stay in order to get home health care set up. You say that you shouldn't have to pay. 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 $20 copayment per day, for days 1-20, per admission. You have been asked to pay a $20 copayment for SNF care. SNF care falls within the "Skilled nursing facility (SNF) 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 waive the copayment for SNF care provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on November 6, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from September 6, 2019 through November 8, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on September 6, 2019 and discharged on September 19, 2019. You were asked to pay a $324 copayment per day from September 6, 2019 through September 10, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 11, 2019, day 6 of your inpatient hospital care until your day of discharge September 19, 2019. Per your contract there is a $324 copayment per day required for days 1-5 for in-network inpatient mental health care. Cost-sharing is charged for each inpatient stay. Furthermore, review of the file shows that you were admitted on October 22, 2019 and discharged on November 8, 2019. You were asked to pay a $324 copayment per day from October 22, 2019 through October 26, 2019, days 1-5 of your inpatient stay. There were no copayment charges from October 27, 2019, day 6 of your inpatient hospital care until your day of discharge November 8, 2019. 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 inpatient mental health care from September 6, 2019 through November 8, 2019 provided by an in-network provider.