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

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided October 14, 2019 to October 21, 2019.You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment should be waived.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 a $285 per-day copayment for days 1-7 for inpatient care.You have been asked to pay a $1,425 copayment for 5 days of inpatient care. 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 inpatient hospital services provided October 14, 2019 to October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says therapy needs can be met outside a rehab hospital at a lower level of care; for example, in a skilled nursing facility.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 3, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until April 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 3, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Initial Hospital Inpatient Care Services (99222) provided June 27, 2018.
You asked the Plan to pay for Initial Hospital Inpatient Care Services. You say that the claim was not billed within the timely statute because the enrollee withheld the information until after such time. The Plan denied your request. The Plan says the claim was not received in a timely manner and no new material evidence was provided with the claim dispute to support that this claim was received in a timely manner.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for Initial Hospital Inpatient Care Services was not filed until February 10, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for Initial Hospital Inpatient Care Services (99222) provided June 27, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit rendered on October 9, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says that procedure code 99217 is a subset to 99266 and not separately payable.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 states that code 99217 (office visit) is a subset to code 99266; however, 99266 is not a valid procedure code. The Plan has not provided any further explanation to support a denial based on Medicare rules.Therefore, we decided that the Plan has to pay for the office visit rendered on October 9, 2019.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services from December 29, 2018 through January 9, 2019.
You asked the Plan to pay for the services. You say that you disagree with how the claim was processed. The Plan denied your request. The Plan says you were covered under another insurance when you were admitted to the hospital.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. You were covered through a different insurance plan in 2018 when you were admitted into the hospital. If a member's disenrollment date occurs during an acute inpatient hospital stay, the effective insurance will be required to pay through the discharge date. Therefore, we decided that the Plan does not have to pay for the services from December 29, 2018 through January 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service the enrollee fell and
there was no way that you could lift him on your own. You called the Fire Department and the responders
helped the enrollee up. You stated that they offered to take him to the emergency room however he felt that he
was not hurt and that it would be a waste to go since he felt okay. You say that he refused transportation to the
hospital and you took him to his doctor later in the week. The Plan denied your request. The Plan says these
services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 9, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that there is no indication that the enrollee's rehabilitation needs are complex or that she needs a rehabilitation physician visit three times a week.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 andnecessary based on Medicare guidelines. 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. 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 16, 2020
through January 18, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay 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 the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from January 16, 2020 through January 18, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99336) provided on November 12, 2019.You asked the Plan to pay fora domiciliary or rest home visit. You say that this provider participates with Medicare.The Plan denied your request. The Plan says the rendering provider is not eligible to participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.Registered Nurses are not eligible to enroll in Medicare.We looked at the file and Medicare rules. The record shows that the rendering provider for the service at issue is a Registered Nurse. Based on this information, we decided that Medicare rules for coverage of a domiciliary or rest home visit have not been met.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit (99336) provided on November 12, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided from August 27, 2019 to September 19, 2019.
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says
that you are responsible for your copayment.
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 $172
copayment for SNF care in a participating SNF.
You have been asked to pay a $516 copayment for the SNF services. The SNF services falls within the days
21-100 of SNF care in a participating SNF 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 skilled nursing facility (SNF) services provided from August 27, 2019 to September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet light therapy system provided by on December 4, 2019.
You asked the Plan to pay for the ultraviolet light therapy system. You say that the ultraviolet light therapy system is medically necessary. The Plan denied your request. The Plan says the medical records do not show a diagnosis of psoriasis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller and expandable controller harness.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not indicate that you require a proportional input devices other than a standard proportional joystick or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the joystick. You do not need an expandable controller to be able to operate one or more of the following: a separate display; other electronic devices or an attendant control. The documentation indicates you have sufficient strength to control the power features through their own individual switches. Our physician reviewer found your condition does not meet criteria for coverage of these items. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection, expandable controller and expandable controller harness.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 19, 2019.
You asked the Plan to pay for the dental services. You say that for dental cleaning per insurance you should have gotten two (2) cleanings per year. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. You exhausted your $1,000 maximum benefit allowance. Therefore, you are responsible for the remainder of the costs. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 29879 is not supported.
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 29879 is arthroscopy, knee, surgical; abrasion
arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture.
We find that CPT code 29879 is not supported in the medical record. Specifically, the operative report does not
include documentation of a surgical knee arthroscopic abrasion arthroplasty. Based on this information, we
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the
Plan does not have to pay for the surgical services rendered on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation -problem focused (D0140) provided on August 5, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied 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 apply in this case.You exhausted your benefit frequency limit, because you had the same service performed on July 8, 2019. Your EOC states, Oral Exam: one (1) every six (6) months.Therefore, we decided that the Plan does not have to pay for limited oral evaluation -problem focused (D0140) provided on August 5, 2019.
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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
status does not require intensive physician or nursing oversight in an IRF. Your medical conditions are chronic
and appear stable and not at a level that requires an IRF admission for monitoring. You may benefit from
additional multiple therapies, however your functional level does not require or indicate that this therapy must
be in an IRF with an intensive level 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OPDIVO (J9299).You asked the Plan to pre-approve OPDIVO. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug regimen is not supported to treat the member's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 OPDIVO. Our reviewer says that the drug is not FDA approved or compendium supported for the requested use. The documentation does not support that the drug is safeand effective for the enrollee. Our physician reviewer found the documentation does not support that the drug is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OPDIVO have not been met.Therefore, we decided that the Plan does not have to pre-approveOPDIVO (J9299).