Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay forthe therapeutic procedures and activities provided on September 14, 2020 and September 16, 2020.You asked the Plan to pay forthe therapeutic procedures and activities. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the enrollee has met the plan year cap limit for therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 therequest to pay for the therapeutic procedures and activities.Our reviewer says that the documentation does support that the services rendered were medically reasonable and necessary. Our physician reviewer found the enrollee has diagnoses of an ataxic gait and unspecified dementia. On September 14, 2020, the enrollee ambulated 1,350 feet with a rolling walker and stand-by assistance. On September 16, 2020, the enrollee ambulated 1,300 feet with a rolling walker and stand-by assistance. The documentation supports that the enrollee's therapy goals had not yet been met in this case, and that continued therapy was medically reasonable and necessary for this enrollee.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 therapeutic procedures and activities have been met.Therefore, we decided that the Plan has to pay forthe therapeutic procedures and activities provided on September 14, 2020 and September 16, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services rendered from March 4, 2020 to March 9, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care services spent on the enrollee. 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 forthe critical care services rendered from March 4, 2020 to March 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an OON provider.

You asked the Plan to pay for nursing facility care. You say that the physician is providing the best possible care to the Plan's enrollees in good faith.The Plan denied your request. The Plan says rules for payment have not been met.

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. There is no documentation in the case record to refute that the Plan did not pre-approve the items/services 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 forthe medical services provided by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cervical collar provided on May 20, 2020.You asked the Plan to pay forthe cervical collar. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized delivery ticket or itemized shipping invoice in the file. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe cervical collar provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 29 to August 24, 2020, by OON provider.You asked the Plan to pay foran intravenous infusion with Simponi. You say that you were not told that infusion for your back was not going to be covered.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on June 29 to August 24, 2020, by OON provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services received from January 22, 2020 to April 30, 2020.You asked the Plan to pay forthe SNF services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received by the enrollee were 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had stable vital signs. The enrollee received oral medications. The enrollee required contact guard/minimal assistance to moderate assistance with functional mobility. The enrollee required varying assistance with activities of daily living. 
The documentation does not support that the enrollee required the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis, at a SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services received from January 22, 2020 to April30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe next generation sequencing (NGS) testing rendered on June 18, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that NGS panels are covered when specific criteria are met.We looked at the file and Medicare rules. The file shows that the enrollee did not receive the testing for a diagnosis for which the testing is covered by Medicare. 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 forthe next generation sequencing (NGS) testing rendered on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered from June 28, 2020 to September 15, 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 there is no valid physician order.
The Plan must follow Medicare rules. The 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 DME. 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 diabetic supplies rendered from June 28, 2020 to September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee cannot live independently without skilled nursing. You say that the enrollee cannot take medications, is not able to move, walk or get out bed on their own.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of SNF care. The Plan says that the enrollee's skilled care needs may be safely met at the current facility.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs.The enrollee does not have documented skilled therapy needs.  The enrollee isambulating more than 100 feet.Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, as a practical matter, can be provided at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal for an anterior tooth
(D3346) for tooth # 9 and the retreatment of a previous root canal for a premolar (D3347) for tooth # 4
provided from August 4, 2020, to August 9, 2020.
You asked the Plan to pay for the dental services. You say that you have no money. You say that you have
sensitivity. You also say that you have broken teeth. The Plan denied your request. The Plan says the
retreatment of a previous root canal is not listed as a covered service.
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
retreatment of a previous root canal for an anterior tooth (D3346) for tooth # 9 and the retreatment of a
previous root canal for a premolar (D3347) for tooth # 4 provided from August 4, 2020, to August 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveD5110 or Complete Denture for the enrollee.You asked the Plan to pre-approvea complete denture. You say that the requested denture is medically necessary.The Plan denied your request. The Plan says this benefit is not currently available as the enrollee receiveda covered denture is May 2019.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 services are not available at this time. Therefore, we decided that the Plan does not have to pre-approveD5110 or Complete Denture for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says these services can be managed at a lower level such as homecare.
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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of the chest.

You asked the Plan to pre-approve a CTA scan of the chest. You say that the CTA of the chest is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the CTA scan.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 a CTA scan of the chest. Our reviewer says that a CTA scan of the chest is not medically necessary at this time. Our physician reviewer found at the current time there is no evidence to support the medical necessity of a CTA chest. The reason for the CTA chest was to determine whether there is persistent thrombus to require continuation of anti-coagulation. However, a recent lower extremity ultrasound has revealed the necessity to continue anti-coagulation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of the chest.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport to an out of network provider.
You asked the Plan to pre-approve transport out of network. You say that you do have a referral from the physician. The Plan denied your request. The Plan says while you may have a referral, transportation is a supplemental benefit and you do not have prior authorization for out of network transport.
Medicare does not cover routine transportation. 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 does not cover transportation out of network. Therefore, we decided that the Plan does not have to pre-approve transport to an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 thedocumentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.The documentation does not support that the enrollee requires at least 3 hours a day /5 daya week, or 15 hours over 7 consecutive days, of therapy services.Medicare coverage criteria are not met. 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe lab services provided on June 18, 2020.You asked the Plan to pay forthe lab services. The Plandenied your request. The Plan says that these services are not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were provided the lab services by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is considered approved by the Plan. You had a reasonable expectation that the services you received would be covered under your plan.Therefore, we decided that the Plan has to pay forthe lab services provided on June 18, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the surgical extraction (D7210), and the surgical placement of an implant (D6010) provided.

You asked the Plan to pay for the dental services. You say that you had a loose tooth that was bothering you so you decided to get it pulled. You say that the root was so long on the tooth that it would not have fallen out on its own. You say that you chose to get an implant to replace the tooth you had pulled. You say that cleanings are supposed to be covered twice per year. You also say that this was just a routine cleaning.The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. 

The Plan says that surgical extractions are not listed as a covered service. The Plan also says that implants are not listed as a covered service.

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 periodontal maintenance (D4910), the surgical extraction (D7210), and the surgical placement of an implant (D6010) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe CT angiography and contrast material provided on December 30, 2019.You askedthe Plan to waive the cost share forthe CT angiography and contrast material. You say that you didn't expect the large deductible and you cannot afford it. You say that you'd like the amount changed.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 $975 for some in-network and out-of-network Medicare-covered services. This is the amount you have to pay out of pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that you must pay 20% coinsurance for medical supplies.The CT angiography you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $975 deductible applies to diagnostic radiology. This cost sharing is a contractual obligation that had not been met at the time the CT angiography was received on December 30, 2019.Therefore, $336.72 has been applied to your deductible.
You have also been asked to pay $18, which is 20% of the allowed amount for the contrast material. (20% x $90 = $18). The contrast material falls within the "Outpatient hospital 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 cost share forthe CT angiography and contrast material provided on December 30, 2019.