Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) provided on October 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the evaluation and management service. You say that the service was medically necessary. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered to the enrollee. The Plan also says that the service was not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. 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 for the home visit (99349) provided on October 5, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 enrollee was admitted for treatment of calciphylaxis wounds due to end stage renal disease. The medical record indicates that because the enrollee is no longer on peritoneal dialysis, the enrollee qualifies for a lover level of care than LTACH. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve battery charger, single mode, for use with only one battery type, sealed or non-sealed, each (CPT code E2366), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The battery charger is already included in the approval of the wheelchair; therefore, the duplicate battery charger is not necessary. Therefore, we decided that the Plan does not have to pre-approve battery charger, single mode, for use with only one battery type, sealed or non-sealed, each (CPT code E2366), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on December 22, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not aware that you would be billed as an outpatient when you saw your doctor at the hospital. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered outpatient surgical service at an in-network outpatient hospital.
You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 arthrocentesis provided on December 22, 2020.
Your complaint that the benefit is unfair 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 waive the copayment for the arthrocentesis provided on September 2, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not aware that you would be billed as an outpatient when you saw your doctor at the hospital. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered outpatient surgical service at an in-network outpatient hospital.
You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 arthrocentesis provided on September 2, 2020.
Your complaint that the benefit is unfair 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 24, 2020 by an out of network provider.
You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an established patient (99336). You say that your provider provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says you did not request prior authorization for the out of network services.
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 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 for the domiciliary or rest home visit provided on September 24, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot walk or stand up without pain. The Plan denied your request. The Plan says you do not have multiple therapy needs.
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 physician reviewer found that you were admitted to the acute care hospital for surgical treatment of bilateral tibial plateau fractures and a lumbar compression fracture after a motor vehicle collision. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial assessment and intervention face-to-face with an individual patient for each 15 minutes of medical nutrition therapy (97802) provided January 19, 2021.
You asked the Plan to pay for medical nutrition therapy services. You say that please review attached documents and reprocess claim accordingly for payment. You are asking the Plan to reimburse as the services were rendered to the enrollee out of medical necessity. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis, therefore does not meet the Medicare criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for initial assessment and intervention face-to-face with an individual patient for each 15 minutes of medical nutrition therapy (97802) provided January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on September 16, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not aware that you would be billed as an outpatient when you saw your doctor at the hospital. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered outpatient surgical service at an in-network outpatient hospital.
You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 arthrocentesis provided on September 16, 2020.
Your complaint that the benefit is unfair 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from December 12, 2019, to December 21, 2019, billed with DRG 175.
You asked the Plan to pay for inpatient care. You say that this was billed with the correct DRG. The Plan denied your request. The Plan says DRG 176 is more appropriate.
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 DRG 175 pulmonary embolism with major complications or comorbidities or acute cor pulmonale. 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 care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the enrollee was diagnosed with pulmonary embolism as well as acute respiratory failure with hypoxia. She was stable on low flow oxygen and experienced transient hypoxia but without work of breathing. The provided records do no support that the patient met the criteria for the diagnosis of acute respiratory failure. Therefore, the DRG 175 was not appropriate and DRG of 176 would have been more appropriate based on the clinical documentation provided. 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 care provided from December 12, 2019, to December 21, 2019, billed with DRG 175.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that this is the only facility that can provide your treatment. The Plan denied your request. The Plan says there is adequate time to schedule services with an in-network provider with no interruption.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve chemotherapy services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four additional crowns provided on December 6, 2020.
You asked the Plan to pay for the crowns. You say that you only received two crowns, and you also have a $2,000 limit per calendar year. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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. Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to two procedures per calendar year. The record shows that you received 6 crowns on December 16, 2020, two of which were covered at the in-network rate by the Plan, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four additional crowns provided on December 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Providence DTRAX cervical cage system.
You asked the Plan to pre-approve the Providence DTRAX cervical cage system. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this request is not medically reasonable and necessary.
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 Providence DTRAX cervical cage system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this 64-year-old female was being treated for status post cervical spine fusion and cervicalgia. She presented with cervical pain. Exam reveals strength and sensation are intact. In this case, there is limited published, large-scale, long-term peer-reviewed literature that
shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Providence DTRX cervical cage system is not medically reasonable or 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 Providence DTRAX cervical cage system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Providence DTRAX cervical cage system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional routine transportation trips.
You asked the Plan to pre-approve 5 additional routine transportation trips. You say that this request is necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 Plan covers a maximum of 48 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 5 additional routine transportation trips.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, blood draw, and testing provided on October 1, 2020.
You asked the Plan to pay for the physician services. You say that the services were not authorized. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit, blood draw, and testing provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided December 28, 2020.
You asked the Plan to pay for the oral hygiene instructions. You say that the EOC is not clear about what is covered. The Plan denied your request. The Plan says this service is not covered under your 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 pay for the oral hygiene instructions (D1330) provided December 28, 2020.
Your complaint about feeling that the Plan documents are too vague 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 pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you do not feel safe switching to a different doctor. The Plan denied your request. The Plan says there are network providers who can see you in a timely manner.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.