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

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that LTACH care is needed.The Plandenied your request. The Plansaysthe enrollee can remain in this current facility.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 casefile 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 patient is currently undergoing treatment at an ACH for Fournier's gangrene. The patient has undergone several surgical debridements and received antibiotics. The enrollee is not intubated/ventilated. 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 LTC 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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.You asked the Plan to pre-approve Vascepa. You say that this is necessary due to the patient's history of heart disease.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.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 pre-approveVascepa.Benefits for Vascepamaybe available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that this is not a preferred test strip with the Plan
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue provider test strips.The provider  is not a preferred provider with the Plan for diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve test strips for the enrollee.
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 the enrollee would benefit from LTACH care.The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility or a lower level of care.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 patient is currently undergoing treatment at an ACH for pneumonia with hypoxia. The enrollee is not intubated/ventilated. 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 LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2D oral or facial photographic images (D0350) provided on October 11, 2019.You asked the Plan to pay forthe dental service. You say that you contacted customer service to find an in network dentist. You say that you were advised you would only pay a copayment. You say that you were not told you would have to pay for dental x-rays. You also say that if you had known the x-rays were not covered, you would have refused them.The Plan denied your request. The Plan says 2D oral facial photographic images 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, 2D oral facial photographic images are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for2D oral or facial photographic images (D0350) provided on October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 20, 2019.You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330).You asked the Plan to pre-approve endodontic therapy (D3330). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the dental services requested are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested endodontic therapy (D3330) is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower denture (D5120).You asked the Plan to pre-approve the lower denture. You say that you never received the bottom denture from the May 5, 2017 date of service. You had to get oral surgery first and you never received the bottom dentures.The Plan denied your request. The Plan says this benefit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The records show that you received a lower denture on May 5, 2017 therefore, this benefit is not eligible until May 5, 2022.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 pre-approve the lower denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for your routine transportation.You asked the Plan to pre-approveadditional miles. You say that you have no other means of transportation to get to your appointment.The Plan denied your request. The Plan says the requested transportation exceeds the 50 mile benefit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows that transportation over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers each one-way trip up to 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional mileage for your routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).
You asked the Plan to pre-approve the dental item. You say that you have a birth defect. You say that your jaw is shifted to the right. You say that you do not have enough bone on the bottom to hold dentures, therefore you need either implants or a new set of fitted dentures. You also say that your dentures no longer fit in your mouth and fall out. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 and dentures are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for a complete lower denture that you received on July 11, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 27, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that you were told by the medical center that the ambulance ride would be covered and you would not have to pay. 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 $300 copayment for each in-network Medicare-covered one-way ambulance trip. You have been asked to pay a $300 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 July 27, 2019
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a breast ultrasound for the enrollee.You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary.The Plan denied your request. The Plan says that the clinical information does not show the results of a recent mammogram.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the ultrasound. Our reviewer says that the requested ultrasound considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a palpable lump in the upper outer quadrant of the left breast and left mammogram and ultrasound of the left breast and axilla are the procedures of choice for evaluation of a palpable mass especially in a patient with prior mastecomy on the right for cancer.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 ultrasound have been met.Therefore, we decided that the Plan has to pre-approve a breast ultrasound for the enrollee.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/orsend 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy visits provided from September 10, 2019 to October 3, 2019You asked the Plan to waive the copayments forthe physical therapy visits. You say that you cannot afford this bill because you are not working. 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 $15 copayment for physical therapy at an in-network outpatient hospital. You have been asked to pay a $15 copayment for each of the physical therapy visits. $15 x 12 visits = $180). The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments forthe physical therapy visits provided from September 10, 2019 to October 3, 2019Your complaint about the short, ineffective services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthoses, and suspension sleeves provided on January 28, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the knee orthoses (L1851), and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.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 underthe 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 forthe lumbar-sacral orthosis, the knee orthoses, and suspension sleeves provided on January 28, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on May 23, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled service.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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure".We find that CPT code 95999 is not supported in the medical record. Specifically,this code was billed for train of four testing. Train of four testing is not an unlisted procedure. There is a CPT code for train of four testing. It is inappropriate to bill CPT 95999 for train of four testing. Additionally, train of four testing is a bundled procedure and cannot be billed separately. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing (CPT 95999)provided on May 23, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a preventive visit (99396) provided on September 6, 2019.
You asked the Plan to pay for the preventive visit. You say that you would like reconsideration as you did not have a previous preventive visit. The Plan denied your request. The Plan says that only one routine physical is covered per calendar year.
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 referred for the preventive visit by the provider, a contract provider. The file does not show that the plan provided notice that the preventive visit would not be covered. Under Medicare rules, this means the preventive visit is considered approved by the plan. Therefore, we decided that the Plan has to pay for a preventive visit (99396) provided on September 6, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided on September 15, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says that services that are considered column II procedures
to another service are not eligible for reimbursement when billed with the column I procedure code.
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice but who
are in different specialties may bill and be
paid without regard to their membership in the same group.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the chest x-ray have been met. Specifically, the services at issue were performed by separate
physicians with different specialties. Therefore, we decided that the Plan has to pay for a chest x-ray (71045)
provided on September 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from August 28, 2019 to September 3, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from August 28, 2019 to September 3, 2019. Therefore, you are responsible to pay a $250 copayment for days 1-6 (August 28, 2019 to September 2, 2019). $250 (copayment) x 6 (inpatient days) = $1,500.You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 foran inpatient hospital stay from August 28, 2019 to September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 24, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).You asked the Plan to pre-approve the dental item. You say that you received dentures in 2018. You say that despite 10 adjustments, they did not fit you right. You say that you dropped them and they broke. You say that they have been repaired and continue to fall apart in your mouth. You say that you need a new denture.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says the frequency limit has been reached.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 and denture are a covered item, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on March 3, 2018.Therefore, we decided that the Plan does not have to pre-approvea complete lower denture (D5120).