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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 2,
2020, through October 4, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care
provided was medically necessary. The Plan denied your request. The Plan says the acute inpatient hospital
care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that the enrollee presented as a direct admission for evaluation of her left
lower extremity that was markedly edematous. Outpatient diagnostic testing revealed a deep vein thrombosis
(DVT) of the femoral vein in the left lower extremity, bilateral subsegmental pulmonary emboli and bilateral
pleural effusion. A thoracentesis was performed, and the enrollee was admitted for a pulmonary embolism,
DVT and pleural effusions. Her physical examination revealed expiratory crackles in the left lung base and
diminished breath sounds in the right lung base as well as left lower extremity edema. She received
subcutaneous Lovenox and Apixaban. She was placed on IV antibiotic therapy for leukocytosis and pending
cultures from pleural fluid. She was discharged home the following day. The review has determined that the
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
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 acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided from October 2, 2020, through
October 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on
May 4, 2020.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 88305 is not supported in the medical record. Specifically, the documentation supports
one unit of this code, which was previously approved and paid by the Plan. There is no additional
documentation supporting an additional study which is being billed. Based on this information, we decided that
Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that
the Plan does not have to pay for the surgical pathology services coded 88305 provided on May 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual,
Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on page 53 of the plan's 2020
Evidence of Coverage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate upper denture (D5130), immediate lower denture (D5140) and several tooth extractions (D7140, D7210).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's mandatory supplemental dental benefit. The enrollee did not choose to enroll in the additional optional dental benefits.

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 pre-approve an immediate upper denture (D5130), immediate lower denture (D5140) and several tooth extractions (D7140, D7210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. 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 November 23, 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 on November 23,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #21.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 pre-approve a crown (D2750) for tooth #21.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January
13, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that this is a hardship for the
enrollee. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is
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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $150 copayment for ambulance services.

The enrollee has been asked to pay a $150 copayment for ambulance services. Ambulance services fall within
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance services provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional accessory for a prosthetic leg (L5850) for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this code is incorrect and cannot be used for the requested knee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this request exceeds the enrollee's need. The physician progress reports do not support the need for
L5850, therefore this request is not medically necessary.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an additional accessory for a prosthetic leg (L5850) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D4381, D4921, D4341, D9630, D0431).

You asked the Plan to pay for the dental services. You say that services were provided in-network and should be covered. The Plan denied your request. The Plan says the requested services (D4381, D4921, D9630, D0431) are not covered under your supplemental benefit. The cost share amount applied for D4341 was correct.

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. The Plan covers specific items and services. The localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), the gingival irrigation - per quadrant (D4921), drugs dispensed in the office for home use (D9630), and adjunctive pre-diagnostic test (D0431) are not among the services listed that are covered by your plan. In addition, the Plan agreed to cover periodontal scaling and root planing - four or more teeth per quadrant (D4341), up to 100% of the Plan's allowed amount, therefore the correct cost share applied to the claim. Therefore, we decided that the Plan does not have to pay for the dental services (D4381, D4921, D4341, D9630, D0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided from January 28, 2020, to December 22, 2020.
You asked the Plan to reimburse you for the dental services. You say that your plan covers 2 cleanings per year. You say that that is the procedure that you received. You say that you are aware that the provider is out of network. You also say that you expect to be reimbursed for these services as this is the provider that you are comfortable with. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider that is not part of our supplemental dental network is 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, care rendered by a provider that is not part of our supplemental dental network is not covered. Additionally, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided from January 28, 2020, to December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) rental.

You asked the Plan to pre-approve continued CPAP rental. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that continuous CPAP coverage is indicated when the enrollee is compliant a minimum of 70% of the time. 

We looked at the file and Medicare rules. Review of the file shows that you had a compliance percentage of only 40%. Based on this information, we decided that Medicare rules for coverage of continued CPAP rental have not been met. Therefore, we decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) rental.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided August 3, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of 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. We find that CPT code G0482 is not supported in the medical record. Specifically, the claim shows a place of service of laboratory (81), however the record shows that the specimen was obtained in the office setting (11). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided August 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Home Health Aide services provided from September 30, 2020, to October 28, 2020.
You asked the Plan to pay for the Home Health Aide services. You say that you were not aware that you needed to use a Plan approved agency. You say that you were never advised by plan representatives that the care needed to be provided by a Plan approved agency, nor that it needed prior authorization. You also say that when you were really confused and needed help and guidance for a stressful and confusing situation, the Plan did not help. The Plan denied your request. The Plan says the services that were provided on the dates of service in this case are considered custodial in nature. The Plan says that custodial care services are not covered by Medicare. The Plan also says that the provider in this case not a participating provider.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Home Health Aide services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the Home Health Aide services provided from September 30, 2020, to October 28, 2020.
Your complaint about the Plan not being helpful 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on September 18,
2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent
or emergent, nor were they 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 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 physician's services that you provided on September 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 8, 2020.

You asked the Plan to pay for the COVID-19 test. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 the COVID-19 test provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing service (V5299) received from the out-of-network provider.
You asked the Plan to pay for the hearing service. You say that you received better care from the out-of-network provider, and you should be reimbursed for some of the cost. The Plan denied your request. The Plan says you must use an in-network provider for hearing services.
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 pays for hearing services only when received from an in-network 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 service have not been met. Therefore, we decided that the Plan does not have to pay for the hearing service (V5299) received from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870, C1821).
You asked the Plan to pre-approve the Vertiflex device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says the use of an interspinous distraction device like Superion is considered investigational. There is not enough medical studies showing this device has been shown to be safe to treat any medical problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870, C1821).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested outof-
network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the
member must receive care from network providers except for emergency care or urgently needed services that
from an out-of-network provider, if you need medical care that Medicare requires our Plan to cover and the
providers in our network cannot provide this care, you can get this care from an out-of-network provider. This
requires prior authorization from the Plan before getting care. Kidney dialysis services at a Medicare-certified
dialysis facility when you are temporarily outside the Plan's service area.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided by the requested out-of-area provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided to you from March 16, 2020, to March 18, 2020.
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted medical records from the in-network provider for the dates of service in question. Without supporting records, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided to you from March 16, 2020, to March 18, 2020.