Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says there are no clinical indications for this technology.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided November 9, 2020 to November 13, 2020.
You asked the Plan to pay for the inpatient services. You say that you have attached a copy of the enrollee's eligibility and it shows that the enrollee still has 60 lifetime reserve days. The Plan denied your request. The Plan says that the benefit has been exhausted as the enrollee has used all lifetime reserve days.
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 failed to provide any supporting documentation of the dates and numbers that inpatient hospital days were used. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided November 9, 2020 to November 13, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of an electrical bladder stimulation device (Yarlap device).

You asked the Plan to pre-approve electrical bladder stimulation device. You say that you need this device to help manage your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you have not failed a 4-week course of an ordered plan of pelvic muscle exercises.

The Plan follows Medicare rules. Medicare rules state that a pelvic floor electrical stimulator may be covered for the treatment of urinary incontinence in patients who have failed a documented trial of pelvic muscle exercise treatment. 

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 electrical bladder stimulation device. Our reviewer says that you do not meet the Medicare criteria for the requested use of electrical stimulator. Our physician reviewer found the records provided show that you have not failed a 4-week ordered exercise program to increase your pelvic muscle strength.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrical bladder stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve use of an electrical bladder stimulation device (Yarlap device).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays provided on February 9, 2021.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays. You say that you were told by two people at the dentist office you were covered with your new insurance. You say that you were not told insurance would only pay a portion of the bill. The Plan denied your request. The Plan says you are responsible for all fees in excess of the Plan payment for services received from an out-of-network dentist.

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, you are responsible for all fees in excess of the Plan payment for services received from an out-of-network dentist. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and bitewing x-rays provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for 2 specialist office visits (99215) and chemotherapeutic treatment (96413) with Durvalumab (J9173) and saline infusion (J7050) provided on January 4 and January 18, 2021.
You asked the Plan to waive the cost-sharing for 2 specialist office visits and chemotherapeutic treatment. You say that your provider told you that the treatment was approved by the Plan and you did not have to pay anything. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for each Medicare-covered Part B drug. Your contract also says that you must pay a $25 copayment for services provided by a specialist.
You have been asked to pay $3,329.40, or 20% of the Medicare-allowed charge of $16,647, for chemotherapeutic treatment. Chemotherapeutic treatment falls within the "Medicare Part B prescription drugs" benefit category. You have also been asked to pay $50, or a $25 copayment per visit, for 2 specialist office visits. Specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 cost-sharing for 2 specialist office visits (99215) and chemotherapeutic treatment (96413) with Durvalumab (J9173) and saline infusion (J7050) provided on January 4 and January 18, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from the provider 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 pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate
inpatient care, and there is no clinical advantage in a transfer to an LTACH.

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 she 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 9, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you do not see the doctor during these visits and the copayments are a real concern for you. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $35 copayment for Physician/Practitioner services, specialist visit. 

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner services, specialist visit 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 specialist office visit provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy services coded 63047 and 63048 provided on November 6, 2020.

You asked the Plan to pay for the laminectomy 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 codes 63047 and 63048 are not supported in the medical record. Specifically, the operative report did not include documentation of a laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], spinal or lateral recess stenosis), for a single lumbar vertebral segment; therefore, code 63047 cannot be verified. The operative report did not include documentation of a cervical, thoracic, or lumbar laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], spinal or lateral recess stenosis), for each additional vertebral segment, (listed separately in addition to code for primary procedure); therefore, code 63048 cannot be verified.

Based on this information, we decided that Medicare rules for coverage of the laminectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the laminectomy services coded 63047 and 63048 provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and electrocardiogram provided on March 1, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit and electrocardiogram. You say that no authorization was obtained because you are in network providers. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.

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 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 office visit and electrocardiogram provided on March 1, 2021 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. The Plan denied your request. The Plan says you will not be able to actively participate in the intensity of services of an IRF.
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 weakness, confusion, urinary tract infection, and a compression fracture in the thoracic spine. Your medical conditions are stable. There are no complex nursing needs.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 the critical care services coded 99291 provided from January 10, 2021 to January 12, 2021.
You asked the Plan to pay for the critical care services. You say that you feel these services should be covered. 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 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided from January 10, 2021 to January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an apartment rental provided in the Republic of Nicaragua from March 10, 2020, to June 10, 2020.
You asked the Plan to pay for apartment rental. You say that the enrollee had a stroke while vacationing in Nicaragua and was released to home care. The Plan denied your request. The Plan says the denial of payment for this service is correct, because an apartment rental is not medical in nature and is therefore not covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services provided outside of the United States are only covered under specific, limited circumstances. The Plan offers a worldwide coverage benefit that goes beyond Medicare's coverage. For that reason, the Plan's coverage rules apply. The Plan covers emergency and urgent care services received outside of the United States when the enrollee cannot get care from a network provider. We looked at the file, the Plan's rules, and Medicare rules. An apartment rental is not medical in nature and therefore is not an emergent or urgent care service. Based on this information, we decided that Medicare rules for coverage of apartment rental have not been met. Therefore, we decided that the Plan does not have to pay for an apartment rental provided in the Republic of Nicaragua from March 10, 2020, to June 10, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that a nursing home setting will not provide the care that is needed. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are 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 that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. 

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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

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 laboratory testing provided on February 12, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on January 23, 2020.

You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), four additional intraoral periapical x-rays (D0230 x4), caries risk assessment and documentation (D0602), and preventive procedure (D1999) provided on March 25, 2021.

You asked the Plan to pay for the intraoral periapical x-rays, caries risk assessment and documentation, and preventive procedure. You say that you went to an in-network provider and do not understand why these services are not covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the first intraoral periapical x-ray (D0220), four additional intraoral periapical x-rays (D0230 x4), caries risk assessment and documentation (D0602), and preventive procedure (D1999) provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from February 13, 2021, to February 24, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that you were not informed you would have a copayment for these services, and you would not have agreed to go if you knew. The Plan denied your request. The Plan says the copayment was applied correctly.
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 each of the first six days of an inpatient hospital stay. You pay nothing after day six. You have been asked to pay a $1,650 copayment for the inpatient services. ($275 x 6 = $1,650). You were admitted on February 13, 2021, and discharged on February 24, 2021. You have been asked to pay a $275 copayment for each of the first six days, but you were not billed an amount for the extra days of your inpatient stay. Inpatient rehabilitation falls within the inpatient hospital care benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from February 13, 2021, to February 24, 2021.