Persius/hicric huggingface dataset:
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 IRF admission is medically necessary as you
have preexisting conditions and can only walk with walker assistance. The Plan denied your request. The Plan
says your necessary services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does
not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing
supervision. You do not require physical and occupational therapy on an intensive rehabilitation facility
therapy program level 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: 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 IRF admission is medically necessary. The Plan denied your request. The Plan says you can receive the necessary services at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You do not require physical and occupational therapy on an intensive rehabilitation facility therapy program level 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance applied for the removal and replacement of the inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session (53447) provided on August 2, 2019.You asked the Plan to adjust the coinsurance for the outpatient surgery. You say that you should only be responsible for the original cost share applied, which was already paid in the amount of $1,153.07.The Plan denied your request. The Plan says you are responsible for a 20% coinsurance for the cost of the outpatient surgery provided.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% coinsurance per visit for outpatient surgery. You have been asked to pay a coinsurance in the amount of $3,746.97(20% X $18,734.84) for the cost of the outpatient surgery provided. 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 adjust the coinsurance applied for the removal and replacement of the inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session (53447) provided on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on February 15, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on February 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay for the ambulance services. You say that you called for the ambulance because at the time you felt that you had needed it. You say that when the ambulance arrived you felt better and did not go to the hospital. You believe the Plan should cover some of the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 24, 2018. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on April 3, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported.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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on April 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the SNF 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 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in an 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 5, 2019.
You asked the Plan to pay for lab services. You say that the claim should be paid. The Plan denied your request. The Plan says under Medicare guidelines Original Medicare is responsible for payment while enrolled in hospice.
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 lab services provided to the enrollee on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram and the tomosynthesis provided on October 16, 2019.
You asked the Plan to waive the deductible for the mammogram and the tomosynthesis. You say that you should not be charged because this is your yearly check-up and it is diagnostic because of your previous cancer. The Plan denied your request. The Plan says the deductible should not apply to diagnostic services and the cost sharing for the services should be a $10 copayment for each service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each basic imaging service (e.g., general x-rays or ultrasound).
You have been asked to pay a $10 copayment for the mammogram and a $10 copayment for the tomosynthesis. The mammogram and the tomosynthesis 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 deductible for the mammogram and the tomosynthesis provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on September 16, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says when you received the dental services, you were not enrolled in the optional supplemental benefits. The Plan also says that the services you received are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on September 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health visit provided on August 8, 2019.
You asked the Plan to waive the copayment for the outpatient mental health visit. You say that the counseling session is considered medically necessary and you should be reimbursed. 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 $10 copayment for each in-network specialist office visit. You have been asked to pay a $10 copayment for the outpatient mental health visit. The outpatient mental health visit falls within the "Outpatient mental health 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 the outpatient mental health visit provided on August 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on April 18, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you did not request the tests. You say that you are disputing the bill.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 for lab services at an in-network freestanding laboratory.You have been asked to pay a $20 copayment for laboratory services. Laboratory services 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 laboratory services provided on April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on September 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on
September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (E0118)
You asked the Plan to pre-approve the crutch substitute. You say that you are not steady on your feet and have balance issues. You have prolonged surgery because you would feel safer with a wheeled scooter. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. While a crutch substitute may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Based on this information, we decided that Medicare rules for coverage of the crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0118)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (tens) device (E0730).
You asked the Plan to pre-approve the tens device. You say that you feel this should be approved because you need this equipment to return to the workforce. This device relieves your pain and you cannot afford the equipment on your own. The Plan denied your request. The Plan says the criteria is not met as the enrollee is not enrolled in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tens device have not been met. Therefore, we decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (tens) device (E0730).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 15, 2019.You asked the Plan to pay for outpatient services. You say that the claim should be paid.The Plan denied your request. The Plan says Original Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.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 Medicarehospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay foroutpatient services provided to the enrollee on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves
(L2397) provided to the enrollee on October 4, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is
medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of
an established relationship between the member and the ordering physician. The Plan states there were no
claims submitted for an evaluation and management service. The Plan states the review of claims history for
this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine
or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeves. Our reviewer says
that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the
documentation in the case file does not support that the requested knee orthoses with sleeves were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's
knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve)
is not separately payable when the base item is not covered.
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 orthoses and sleeves have not been met. Therefore, we decided that the Plan
does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the
enrollee on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (code
D6057) and abutment supported porcelain/ceramic crown (code D6058) provided on October 10, 2019.
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that
your dentist office called your insurance company prior to the services being rendered so they could tell you
what your portion would be. You also say that you believed the Plan would cover some of the cost is because it
was for a crown. The Plan denied your request. The Plan says these services are not included on your plan
benefit schedule and are not covered services.
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
custom fabricated abutment - includes placement (code D6057) and abutment supported porcelain/ceramic
crown (code D6058) provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided by an out-of-network provider on August 29, 2019.
You asked the Plan to pay for vision services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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 vision services have not been met. The Health Plan reimbursed issued payment to you in the amount of $150 on October 15, 2019. You confirmed you have received the $150 from the Health Plan. You are responsible for any amount above the eyewear coverage limit. Therefore, we decided that the Plan does not have to pay for vision services provided by an out-of-network provider on August 29, 2019.