Persius/hicric huggingface dataset:
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
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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for low back pain. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abdominoplasty.
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) (15847). You say that you need abdominoplasty because the extra skin is causing medical problems. The Plan denied your request. The Plan says a panniculectomy is approved but an abdominoplasty is cosmetic and therefore not covered.
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 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) (15847). Our reviewer says that the
requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has had massive weight loss following bariatric surgery. Panniculectomy has been approved. The medical records indicate that the abdominoplasty is for contouring purposes. The abdominoplasty is not medically necessary and reasonable as defined by Medicare rules. The elements of the coverage rule are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) (15847) have not been met. Therefore, we decided that the Plan does not have to pre-approve abdominoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 21, 2021.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered though the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were ordered from a provider that is not a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy and retrograde filling provided on January 19, 2021.
You asked the Plan to pay for the apicoectomy and retrograde filling. You say that you would like these services to be covered. The Plan denied your request. The Plan says these procedures 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 apicoectomy and retrograde filling provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care services provided on October 10, 2020.
You asked the Plan to waive the copayment for emergency care services. You say that you waited in the lobby for forty-five (45) minutes, and you were never seen. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. The plan states they confirmed that you were in triage and may have received blood pressure tests, etc., while waiting to be seen; therefore, you were charged for your visit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received emergency care services on October 10, 2020. You were asked to pay a $90 copayment for the emergency care. Your 2020 EOC states that enrollees must pay a $90 copayment for each emergency room visit. 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 emergency care services provided on October 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 11, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that according to your benefits, you should have a $0 copayment for the ultrasound. The Plan denied your request. The Plan says you have been asked to pay 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 a $75 copayment for in-network diagnostic procedures and tests, including ultrasounds, at all locations of services.
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound falls 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 copayment for the ultrasound provided on January 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transport services provided on October 28, 2020.
You asked the Plan to pay for the non-emergency ambulance transport 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transport services provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for diabetic supplied billed with Healthcare Common Procedure Coding
System (HCPCS) codes A4259 and A4253 for dates of service February 19 - May 19, 2020.
You asked the Plan to pay for the diabetic supplies. You say that the documentation provided is sufficient and
shows that the items in dispute were delivered to the enrollee. The Plan denied your request. The Plan says that
the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific
supplies, or proof of delivery.
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 rules also say that acceptable proof of delivery requires that the supplier's record be linked to the
delivery service record by some clear method like the delivery service's package identification number or
supplier's invoice number for the package sent to the beneficiary.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has not substantiated their denial reason that the
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies,
or proof of delivery. We found that a detailed invoice was provided which was linked to the delivery
confirmation for the items in dispute. Therefore, we decided that the Plan does not have to pay for diabetic
supplied billed with Healthcare Common Procedure Coding System (HCPCS) codes A4259 and A4253 for
dates of service February 19 - May 19, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus (CPT code 90715) and immunization administration
(CPT Code 90471) provided on November 19, 2020.

You asked the Plan to pay for the services. You say that you are requesting reimbursement because the code
was wrong as it should have been coded as preventative. The Plan denied your request. The Plan says CPT
code 90715 was not billed with an appropriate diagnosis that would allow for processing under Medicare Part
B. The Plan states as they are unable to process the vaccine/immunization under Medicare Part B,
administration code 90471 will also remain denied.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.

The tetanus vaccination service code 90715 denied because payment is not allowed for this vaccination because it was billed with a non-covered diagnosis per your policy. CPT Code 90471 denied because the vaccine administration is not covered when no corresponding vaccine is billed. Therefore, we decided that the Plan does not have to pay for tetanus (CPT code 90715) and immunization administration (CPT Code 90471) provided on November 19, 2020.

Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on August 20, 2018.
You asked the Plan to pay for the ambulance services. You say that The Plan denied your request. The Plan
says the services rendered should be paid through workers compensation, as the ambulance transportation was
provided just 12 days after the enrollee's fall at work.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for ambulance services provided on August 20, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 14, 2019 to February 18, 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 the records do not support the billed DRG and diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 308 and diagnosis code G92 (toxic encephalopathy). 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 these services. Our reviewer says that the records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee presented to the hospital with confusion and aggressive behavior. While an elevated digoxin level was noted, this was treated and resolved with the patient remaining confused and agitated. The progress notes indicated that the enrollee had been known to have Alzheimer's dementia with behavioral disturbance. Psychiatry was consulted and the discharge summary noted that the patient was taken to the geropsychiatry unit for further treatment due to persistent confusion and agitation. AMS associated with neurodegenerative processes or dementia should be coded with the appropriate combination code from the F series and not as encephalopathy. In this case, F02.81 (Dementia in diseases classified elsewhere, with behavioral disturbance) had already been assigned. The records did not support the billing of DRG 308 and diagnosis code G92 (toxic encephalopathy). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from February 14, 2019 to February 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership fees for January and February of 2021.

You asked the Plan to pay for the gym membership fees for January and February of 2021. You say that the
Plan should pay for the membership fees. The Plan denied your request. The Plan says you cannot apply your
2020 fitness benefit toward membership fees in 2021.

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 have a $150
allowance towards health and wellness services in 2020.

You submitted a request for reimbursement to the Plan for three months-worth of gym membership fees
(December, January, and February). The Plan agreed to apply $51 towards the December 2020 monthly fee, in
addition to a $40 one-time fee. The Plan is not required to apply 2020 benefits toward 2021 membership fees.
If you are seeking reimbursement using your 2021 benefits please resubmit the claims for January and
February to your 2021 plan. Therefore, we decided that the Plan does not have to pay for the gym membership
fees for January and February of 2021.
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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.