Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the 30-day supply of wound care supplies provided on February 20, 2020.
You asked the Plan to waive the coinsurance for the wound care supplies. You say that you cannot pay the bill and would like it cancelled. 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 20% coinsurance for Medicare-covered DME items and certain drugs that are used with nebulizers, insulins pumps, and IV infusions pumps. You have been asked to pay a total of $235.58 which is 20% of the allowed amount for the wound care supplies. The allowed amount is $1,177.86. ($1,177.86 x 20% = $235.58). The wound care supplies fall within the "Durable Medical Equipment (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 the 30-day supply of wound care supplies provided on February 20, 2020.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is
mostly moderate to maximum assist for functional transfers and upper body activities of daily living (ADL's)
and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be
able to fully benefit and/or participate in an IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 the office visit (99201) provided on February 11, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not a covered benefit under your contractual policy.
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 the office visit (99201) provided on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 31, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $175 copayment for ambulance services. You have been asked to pay a $175 copayment for ambulance services. Ambulance services fall 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 for ambulance services provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a spinal neurostimulator pulse generator.
You asked the Plan to pre-approve the insertion of a spinal neurostimulator pulse generator. You say that there was success with the trial and that proceeding with the permanent is medically appropriate. The Plan denied your request. The Plan says the records provided do not show evidence of a psychological evaluation and therefore the requested service is not medically 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 insertion of a spinal neurostimulator pulse generator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found there is no documentation of a trial of epidural steroid injections, there is no record of PT completion, and there is no formal psychological evaluation. There is no documentation of surgical consultation regarding the lumbar degenerative discs. 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 insertion of a spinal neurostimulator pulse generator have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a spinal neurostimulator pulse generator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living care provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for assisted living care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for assisted living care provided on November 15, 2019 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee required moderate assistance times two for bed mobility and bed to chair
transfers. The documentation does not support that the complexity of the enrollee's nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care in an IRF currently. The enrollee's medical status appears to continue to require care in the
acute hospital. While the enrollee may benefit from further physical therapy and occupational therapy, the
enrollee does not support that the enrollee's functional status can tolerate an intensive rehabilitation therapy
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant-360/NEXT-Generation molecular pathology
testing provided to the enrollee on February 18, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says service providers should use CPT 81479 for this testing.
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 81479 is "unlisted molecular pathology procedure."
We find that the multitude of denied codes on this claim are not supported in the medical record. Specifically,
the denied testing must be reported with CPT 81479. 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 for
Guardant-360/NEXT-Generation molecular pathology testing provided to the enrollee on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care (99308) provided on January 10, 2020.You asked the Plan to pay fornursing facility care. You say that this service was medically necessary.The Plan denied your request. The Plan says authorization for this service was denied and there were in-network providers available.The Plan must followMedicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay fornursing facility care (99308) provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea flexible protective outer surface covering system.You asked the Plan to pre-approvethe protective outer cover. The Plan denied your request. The Plan says the artificial leg will not be used in very harsh conditions.The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering are used by a beneficiary who has special needs for protection against unusually harsh environmental situations.We looked at the file and Medicare rules. The documentation provided does not indicate that your prosthesis needs protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea flexible protective outer surface covering system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe  acute inpatient rehabilitation facility (IRF) services provided on December 27, 2019 to December 31, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe IRF services. You say that this admission was warranted and supported by clinical documentation in the medical record.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being renderedMedicare 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 hasnetwork providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided thatthe Plan does not have to pay forthe  acute inpatient rehabilitation facility (IRF) services provided on December 27, 2019 to December 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living facility care provided on February 10, 2020 by an out of network (OON) provider. You asked the Plan to pay for assisted living facility care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the assisted living facility is also out-of-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for assisted living facility care provided on February 10, 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the clinical documentation supports the medical and functional need for care in an IRF. The Plan denied your request. The Plan says the guidelines for IRF care have not been met. The Plan says that the enrollee can safely receive the services needed, in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 18, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that there is not a statement in the Plan's 2020 Annual Changes about in or out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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. Review of the file show that you received periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 18, 2020 by an out-of-network provider. For code D0120, the provider billed the plan $47.00. The allowed amount for the service is $20.00, and the plan paid $20.00. You are responsible for all fees in excess of the allowed amount, $27.00 ($47 - $20). For code D1110, the provider billed the plan $80.00. The allowed amount for the service is $43.00, and the plan paid $43.00. You are responsible for all fees in excess of the allowed amount, $37.00 ($80 - $43). Your EOC states, "providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. You may be billed more by an out-of-network provider if the charge is greater than MAC." Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 18, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150) and intraoral -complete series of radiographic images (D0210) provided on March 9, 2020.You asked the Plan to pay forthe dental services. You say that you did not know that the x-ray done was not included in your insurance.The Plandenied your request. The Plan says you exhausted your benefit frequency limit.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 applyin this case.You exhausted your benefit frequency limit because you had the same services performed on February 14, 2019. Your EOC states, a comprehensive oral evaluation -new or established patient (D0150) is covered one (1) procedure every three (3) plan years and intraoral -complete series of radiographic images (D0210) is covered one (1) procedure every three (3) plan years.Therefore, we decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150) and intraoral -complete series of radiographic images (D0210) provided on March 9, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe skilled nursing facility services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says the enrollee does not require daily skilled services at an inpatient level.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee's needs can be met on an outpatient 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 skilled nursing facility services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
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 clinical information provided supports the need
for IRF care. You say that the enrollee wants to return to being completely independent and self-sufficient. The
Plan denied your request. The Plan says the records show the enrollee is very weak and that it is not reasonable
to expect the enrollee to be able to take part in 3 hours of therapy a day at least 5 days a week, or 15 hours a
week. The Plan says that the enrollee does not need to see a rehab doctor 3 times a week. The Plan says that the
enrollee can safely receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 the medical services provided to you by an out-of-network provider on March 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on March 9, 2019.