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

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 15, 2020, through March 18, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission is 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the enrollee was admitted from March 15, 2020 through March 18, 2020 due to pleuritic chest pain and was found to have lung consolidation, a moderate sized pericardial effusion increased from previous and a right sided pleural effusion that was drained. The enrollee had recently completed a course of steroids for presumed interstitial lung disease. The documentation supports the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record. The elements of the coverage rule are satisfied. The requested service is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 15, 2020, through March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe
gingival inflammation (D4346).
You asked the Plan to pre-approve scaling in presence of generalized moderate or severe gingival
inflammation. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan
says the service at issue is not a covered benefit.
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
scaling in presence of generalized moderate or severe gingival inflammation (D4346).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CARIS MI profile genetic testing.
You asked the Plan to pre-approve CARIS MI profile. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that only certain genetic testing is covered. We looked at the file and Medicare rules. Review of the file shows that the requested genetic testing is the CARIS MI profile. The MI profile by CARIS is not listed as a Medicare covered service on DEX Diagnostics by Palmetto GBA. Based on this information, we decided that Medicare rules for coverage of CARIS MI profile have not been met. Therefore, we decided that the Plan does not have to pre-approve CARIS MI profile genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services coded 97168 provided on
September 9, 2020.
You asked the Plan to pay for the occupational therapy 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.
In this case, the CPT Code Manual definition of code 97168 is re-evaluation of occupational therapy
established plan of care, requiring these components: an assessment of changes in patient functional or medical
status with revised plan of care; an update to the initial occupational profile to reflect changes in condition or
environment that affect future interventions and/or goals; and a revised plan of care. A formal reevaluation is
performed when there is a documented change in functional status or a significant change to the plan of care is
required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
We find that CPT code 97168 is not supported in the medical record. Specifically, the documentation shows
that thee services were performed in the home setting. This means there is a more appropriate code that should
be used to bill the services rendered. Based on this information, we decided that Medicare rules for coverage of
the occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay
for the occupational therapy services coded 97168 provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (CPT 97530) received on February 23, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan's coverage does not provide for this service when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (CPT 97530) received on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoes and inserts.
You asked the Plan to pre-approve orthopedic shoes and inserts. 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 items.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes and inserts.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Isosource 1.5 oral liquid nutritional supplement.
You asked the Plan to pre-approve the services. You say that this is your only source of food. The Plan denied your request. The Plan says nutritional supplements or formulas that are administered orally that do not serve a primarily medical purpose are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Isosource 1.5 oral liquid nutritional supplement.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for post-cataract laser surgery provided on October 1, 2020.
You asked the Plan to waive the copayment for post-cataract laser surgery. You say the provider advised you that the procedure was a continuation of the previous surgery and you would not get billed for the office visit. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $30 copayment for an outpatient physician visit, for vision care.
You have been asked to pay a $30 copayment for post-cataract laser surgery. The EOC confirms that $30 is the required copayment for this service. Post-cataract laser surgery falls within the vision care benefit category. You received this service outside of the 90-day limit for it to be covered as part of the surgery. 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 post-cataract laser surgery (66821) provided on October 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy injections provided on December 29, 2020.
You asked the Plan to waive the coinsurance for chemotherapy injections. You say that there should not be a cost share and you have never had to pay one before. The Plan denied your request. The Plan says the cost share is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for chemotherapy injections for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for chemotherapy injections for chemotherapy injections. This service falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy injections provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture provided on February 3, 2021.

You asked the Plan to pay for the mandibular partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says you have met your annual maximum benefit.

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 Plan offers a $0 copay up to the $1,000 allowance for all covered dental services. The contract says that you pay 100% of charges beyond the $1,000 allowance or if you exceed a service limit. The record shows that you met the annual maximum benefit while processing this claim for the February 3, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 14, 2020.
You asked the Plan to pay for the office visit. You say that you spoke with the Plan to let them know you were moving and needed to establish care as soon as possible. You say that telehealth visits are supposed to be covered and the Plan should pay the claim. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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. The records show your new plan did not start until January 1, 2021. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a paravertebral facet joint block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for repeat injections.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has previously undergone diagnostic injection and radiofrequency ablation with persistence of headache improvement. The enrollee is now having neck pain radiating to shoulder and arm. The enrollee is undergoing treatment with physical therapy that has not been completed as of the request date. The requested service is for both diagnosis and therapeutics. The medical records do not indicate that the coverage criteria of either have been completely satisfied. 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a paravertebral facet joint block for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says you can stay in the hospital to finish treatments.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical trial and related services.
You asked the Plan to pre-approve the services. You say that your last three physicians suggested this trial start
in a reasonably prompt timeframe. The Plan denied your request. The Plan says this is the responsibility of
Traditional Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the services as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
clinical trial and related services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on November 18, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you had this procedure in
2020. You say that you already paid $200. The Plan denied your request. The Plan says the correct copayment
has been applied.
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 $275
copayment for outpatient surgery/in-network/outpatient hospital.
You have been asked to pay a $275 copayment for an outpatient surgery. The correct copayment has been
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/innetwork/
outpatient hospital 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 an
outpatient surgery provided by a participating provider on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on October 3, 2020.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have been compliant for over three years and request that the Plan pay for 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 20% coinsurance for DME and related supplies. 

You received DME and related supplies on October 3, 2020. The total allowed amount is $84.16 and 20% of that is $16.83.

You have been asked to pay the total coinsurance amount of $16.83 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on October 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma (PRP) treatment you received on October 13, 2020.

You asked the Plan to pay for the PRP treatment. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that PRP will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds and only when the patient is enrolled in a clinical trial.

We looked at the file and Medicare rules. The submitted documentation does not show that you are enrolled in a clinical trial for PRP treatment. Based on this information, we decided that Medicare rules for coverage of the PRP treatment have not been met. Therefore, we decided that the Plan does not have to pay for the platelet rich plasma (PRP) treatment you received on October 13, 2020.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted after being found down at home and was noted to have atrial fibrillation with rapid
ventricular response and hypoxic respiratory failure due to pneumonia. The enrollee continues to receive acute
care services that have not been denied. The medical records provided do not indicate that the enrollee requires
acute care services that he is not currently receiving that would be available at the LTACH. 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.