Persius/hicric huggingface dataset:
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving the appropriate in-patient care and does not require transfer to an LTACH.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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: 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 physical therapy is needed for your foot as you are unable to do things for yourself and need to get back to normal activities and get back to how you were before. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for seizures and surgical repair of an ankle fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation provided on March 2, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you would like the Plan to pay 100% for this service, and not apply the charge toward your $500 annual benefit maximum. The Plan denied your request. The Plan says this service must be applied toward your $500 annual benefit maximum.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are requesting that the Plan pay for this service in full, and not deduct the payment from your annual $500 dental allowance. This service is not listed as one of the exceptions that does not apply toward the annual $500 maximum benefit, and the charge has correctly been deducted from your annual maximum benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 5, 2020.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says providers should use the diagnosis code for billing that describes the patient's diagnosis, symptom, complaint, condition or problem to the highest level of specificity. In this case, the records do not support the billing of diagnosis code I70.213. There is a more appropriate diagnosis code for the services provided laterally. Therefore, we decided that the Plan does not have to pay for the physician services provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator rendered on August 14, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was 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% coinsurance for Medicare-covered durable medical equipment and related supplies.
Review of the file shows that you received a bone growth stimulator on August 14, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered durable medical equipment 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 bone growth stimulator rendered on August 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete unilateral breast ultrasound (76642) provided November 23, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you received a bill for $100 and was informed you need to pay because the plan denied. You are upset that the ultrasound was not covered in times of a pandemic and feels it should be covered in full. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $100 copay for ultrasound services. You have been asked to pay $100 copay for the breast ultrasound. The breast ultrasound 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 complete unilateral breast ultrasound (76642) provided November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from
January 11, 2021, to January 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 had network providers
available who could have provided 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 services provided by an out-of-network provider from
January 11, 2021, to January 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 15, 2020.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from July 5, 2019 through
July 9, 2019 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for inpatient services provided from July 5, 2019 through July 9, 2019 with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says the medical record received and available for review does not support the condition treated as consistent with a systemic infectious process.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with reported principal diagnosis A41.9, sepsis, unspecified organism. 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 inpatient services provided from July 5, 2019 through July 9, 2019 with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation indicates that the enrollee was evaluated and admitted on July 5, 2019 for Pressure Ulcer of Sacral Region, Stage 4. The documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis is documented in the progress notes by the MD, supporting medical record documentation was not found within the record. The enrollee presented to the ED with fever. The appeal note mentions pulse of 97 and respiration rate of 22. Though pulse of 97 and respiration rate of 22 are noted on arrival, these values promptly improved with treatment in the ED. There was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. There was no renal or hepatic impairment and the enrollee remained hemodynamically stable. Moreover, the documentation did not support a rise on SOFA score 2 or more points in the SOFA score that cannot be easily explained by causes other than sepsis. There is no evidence of significant physiologic instability. The review has determined that the principal diagnosis A41.9, sepsis, unspecified organism was not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from July 5, 2019 through July 9, 2019 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from October 19, 2020, through October 22, 2020.
You asked the Plan to pay for the ambulance services. You say that this service was necessary due to your diagnosis with Covid and being far away to the nearest hospital. 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 October 19, 2020 to October 22, 2020. 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 for the ambulance services provided from October 19, 2020, through October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from December 18, 2020, to December 19, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you did not ask for these or any other drugs while you were in the hospital. You say that you did not think you had a choice about whether you had to take the medications that were brought to you. You also say that you have been told in the past that you cannot bring your own medicine into the hospital. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from December 18, 2020, to December 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on November 6, 2020.
You asked the Plan to pay for the hearing aids. You say that these hearing aids are the most beneficial for you. You feel they should be covered because they are effective, and it is unfair for the Plan to only cover certain types of hearing aids. The Plan denied your request. The Plan says you used the Plan's required provider; however, you chose to purchase hearing aids that are not included on the Plan's formulary. You received a discount at the time of purchase, but the hearing aids you selected are ineligible for reimbursement. The hearing provider informed you of this at the time of purchase.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan will pay only for the hearing aids listed on the formulary when they are provided by the Plan's provider.
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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January
12, 2021.
You asked the Plan to waive the copayment for these services. You say that you were billed for a preventive
visit. The Plan denied your request. The Plan says the copayment was 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 $40
copayment for Medicare-covered specialist services.
Review of the file shows that you received specialist services on January 12, 2021. You have been asked to pay
a $40 copayment for these services. These services fall within the Medicare-covered 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 the specialist services rendered on January 12,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (34713) provided on August 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 34713 is 1. You billed 2 units of this code, exceeding the MUE. 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 the services (34713) provided on August 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on January 7, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the most appropriate code.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, there is a more appropriate code for the specific services rendered, G2168 (services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes). Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device (E0730) with electrical stimulator supplies
(A4595) and lead wires (A4557) provided on October 22, 2020.
You asked the Plan to pay for a TENS device with electrical stimulation supplies and lead wires. You say that
the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for a
TENS device and accessories are not met.
The Plan must follow Medicare rules. Medicare rules say that a TENS device for treatment of CLBP is covered
when the enrollee is participating in an approved clinical study.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a TENS device with electrical stimulation supplies and lead wires have not been met. Specifically,
you are not participating in an approved clinical study. Therefore, we decided that the Plan does not have to
pay for a TENS device (E0730) with electrical stimulator supplies (A4595) and lead wires (A4557) provided
on October 22, 2020.