Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 19, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on October 18, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for CT scans provided on May 20, 2019, and November 25, 2019.

You asked the Plan to waive the coinsurance for CT scans. You say that you disagree with the charges because you were never charged in the past. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 co-payment for radiological diagnostic services.

You received a CT scan on May 20, 2019. Therefore, you are responsible to pay the $100 co-payment.

You received a CT scan on November 25, 2019. Therefore, you are responsible to pay the $100 co-payment.

The total amount you owe is: $200.

You have been asked to pay the total co-payment amount of $200 for CT scans. CT scans fall within the outpatient diagnostic tests and therapeutic services and 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 CT scans provided on May 20, 2019, and November 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 18,
2020, by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be
reprocessed for payment. The Plan denied your request. The Plan says the service was rendered by a nonparticipating
provider. The Plan also says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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
August 18, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
November 18, 2020, through November 19, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that The Plan denied your request. The Plan says based upon records available, the care delivered is consistent with an observation stay. There is no medical necessity for formal hospitalization.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the ED with abdominal pain for 2-3 weeks with constipation and recent diarrhea after taking magnesium citrate. He had no vomiting, no fever/chills. Vitals 97.8, P118, BP183/106, R18, 97%RA. No acute distress, normal bowel sounds, soft, tender to right upper quadrant, no rebound or guarding, no CVA tenderness, no mass. GCS 15 with normal gait and strength. Sodium 126, CRP 11.9, albumin 3.4. CT abdomen showed lesions and lymphadenopathy suggestive of metastatic disease and thickening of distal sigmoid colon without evidence of diverticulosis. A colonoscopy was recommended. The enrollee did not meet sepsis criteria and required fluids only and short-term monitoring. There was no indication that the enrollee would require hospital services that would likely cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 18, 2020, through November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Apple watch purchased November 21, 2020.
You asked the Plan to pay for the Apple watch. You say that you need the Apple watch to track your heart rate
to monitor your atrial fibrillation and to monitor you for falls. The Plan denied your request. The Plan says the
Apple watch is not a covered item.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a health and wellness 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 Apple watch purchased November 21, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve corn removal surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary, as it is very painful. The Plan denied your request. The Plan says that this surgery would not provide a successful outcome.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have had multiple reconstructive surgeries on her foot resulting in shifting weight-bearing loads and pain. The provider's record indicates consideration of both conservative and surgical management with long range plans. Acknowledging that judgement between experts may vary, the documentation provided supports the medical necessity and reasonableness of the requested service. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve corn removal surgery.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not being treated for any of the covered conditions.
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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have "failed back syndrome" or "post-laminectomy" syndrome which are indications for which this services is generally covered. (She otherwise does not have another diagnosis for which this service is otherwise covered). This is not being requested as a last resort. There is no indication that the enrollee has been in for a surgical evaluation. It is therefore unclear if surgery is an option. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 8, 2020.

You asked the Plan to pay for the prophylaxis. You say that you believe this service should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limitation for this service.

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, prophylaxis (D1110) is limited to twice per every 1 plan year. The record shows that you received a prophylaxis (D1110) on February 4, 2020, and August 12, 2020 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 12, 2020, through August 24, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were rushed to the hospital for a medical emergency and stayed by a doctor's order. You say that this should be made an end of year write off. The Plan denied your request. The Plan says the copayment 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 $25 copayment per day, days 1 to 8 for each in-network, inpatient hospital stay. You have been asked to pay a $200 copayment for the inpatient stay. ($25/day x 8 days = $200). The inpatient stay 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 stay provided from August 12, 2020, through August 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you from October 29, 2020, to November 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you from October 29, 2020, to November 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0428) provided on October 24, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $225 copayment for each Medicare-covered one-way trip by ground ambulance transportation. 

You have been asked to pay a $225 copayment for the Medicare-covered one-way ground ambulance trip provided. On this day, two Medicare-covered one-way ground ambulance trips were provided by different ambulance companies. 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 ambulance transportation service (A0428) provided on October 24, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lower extremity
weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that this
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on November 2, 2020.
You asked the Plan to pay for the laboratory 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 payable.
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 CPT code 81479 is not supported in the medical record. Specifically, the documentation does not support that this testing was ordered/approved by the ordering provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479 provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the unspecified endodontic service (D3999), the unspecified preventive service (D1999 x 2), gum surgery (D4249), canal preparation and fitting (D3920), the unspecified restorative service (D2999), and the post and core in addition to a crown (D2952) provided from October 20, 2020, to October 29, 2020.

You asked the Plan to reimburse you for the unspecified services, the gum surgery, canal preparation and fitting, and the post and core in addition to a crown. You say that the dentist demanded full payment from you on the date of service. You also say that these services should be covered.The Plan denied your request. The Plan says the services you received are not listed as covered services.

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 reimburse you for the unspecified endodontic service (D3999), the unspecified preventive service (D1999 x 2), gum surgery (D4249), canal preparation and fitting (D3920), the unspecified restorative service (D2999), and the post and core in addition to a crown (D2952) provided from October 20, 2020, to October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the
periapical x-ray (D0220) provided on January 5, 2021.
You asked the Plan to reimburse you for the dental services. You say that these services should be covered. The
Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says
that periapical x-ray is not listed as a covered service either.
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 reimburse you for
the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology testing provided on September 10, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. 

We find that the lab testing is not supported in the medical record. Specifically, the limited medical records provided do not indicate the results of the testing correlates with given interventions. 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 pay for the molecular pathology testing provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 4, 2020.
You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the orthoses are medically necessary. The Plan denied your request. The Plan says the orthoses are not supported in the medical records received.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 4, 2020.