Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need the shower chair because you have bad knees. You say that you have fallen previously because you are unable to bend down. You asked the Plan to reconsider providing coverage for the requested shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on April 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II code.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part of an edit pair with procedure code 74022. Procedure code 74022 is a column one code, and procedure code 71045 is a column two code. Procedure code 74022 has been paid for this date of service, which means that procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 71045) provided on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 8, 2019 and November 12, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says your health plan benefit packet requires the use of in-network providers other than in urgent or emergent situations.
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 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 physician's services provided on August 8, 2019 and November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on February 11, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you should not have to pay for this service due to the wait time. The Plan denied your request. The Plan says this processed 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 $10 copayment for Medicare-covered X-rays. You have been asked to pay a $10 copayment for an x-ray. 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 an x-ray provided on February 11, 2020.
Your complaint about the time you waited for this service 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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a facility sleep study (diagnostic attended polysomnography).
You asked the Plan to pre-approve a facility sleep study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facility sleep studies are covered for certain indications. 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 a facility sleep study. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a BMI of 35. The enrollee has loud snoring. The enrollee has an Epworth score of 2. The enrollee has a previous diagnosis of obstructive sleep apnea (OSA). A diagnostic attended PSG is considered reasonable and necessary for this enrollee. Home sleep studies are indicated when there is a high suspicion of obstructive sleep apnea (OSA). Because this enrollee does not have excessive daytime sleepiness, the suspicion of OSA is moderate but not high.
The enrollee has polycythemia, which can result from chronic hypoxemia, and therefore careful monitoring of oxygen saturation, and the capability of providing oxygen during the study, are preferred. Other sleep-related disorders are possible that would not be detected with a home study. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a facility sleep study have been met. Therefore, we decided that the Plan has to pre-approve a facility sleep study (diagnostic attended polysomnography).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion or replacement of the cranial neurostimulator pulse generator (61886) provided on March 30, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for surgery performed at an in-network outpatient hospital facility. You have been asked to pay a $2,932.40 coinsurance ($14,662 billed amount x 20% coinsurance) for surgery performed at an in-network outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the insertion or replacement of the cranial neurostimulator pulse generator (61886) provided on March 30, 2020.
Your complaint about your advisement from the financial counselor at the physician's office for this service 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says custodial care is excluded from coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. The enrollee's functional level is near baseline and
the enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a
qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.
The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on
a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an
inpatient basis, in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on August 4, 2019.
You asked the Plan to pay for the emergency room services. You say that The Plan denied your request. The Plan says the claim in dispute is a duplicate charge considered on a previous claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records show that the claim in dispute (820192540397342) is an exact duplicate of claim number A19292773789. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided on August 4, 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 you are functioning at a level where therapy needs can be safely met at a lower level of care in the subacute 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 you were medically stable after spine surgery, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, given your current level, though you need PT and OT, you do not require the IRF level of therapy. You may benefit from PT and OT, but you do not require an intensive therapy program. The admission is not medically necessary, based on the enrollee's current functional status, and lack of medical complexity. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the neck spine (72125).
You asked the Plan to pre-approve a CT scan of the neck spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the neck spine. Our reviewer says that the services are medically necessary. Our physician reviewer found this enrollee has been educated concerning home exercises and stretching and continues to do these however has worsening of left shoulder and neck pain exacerbated with rotation. While there are no red flags listed in the records the impression of a possible C1-2 cause of symptoms is worrisome and the best way to assess the boney architecture of the cervical spine would be the requested CT scan. While a trial of 6 weeks of conservative management including physical therapy (PT) would ordinarily be required prior to authorizing a CT the enrollee continues to do home exercises and has increasing and debilitating pain with cervical motion. Thus, in this case the CT scan should be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the neck spine have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the neck spine (72125).
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: Testing
Decision: Favorable

We decided that the Plan has to hold you harmless for an aortic ultrasound (76706) provided on March 3, 2020.
You asked the Plan to hold you harmless for the aortic ultrasound. You say that you would like reconsideration because the copay should not be more than the contracted amount. The Plan denied your request. The Plan says that the member previously received an abdominal aortic aneurysm therefore, this benefit is exhausted.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the aortic ultrasound by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the aortic ultrasound would not be covered. Additionally, the Plan failed to forward sufficient information to show that this service had been previously rendered. Under Medicare rules, this means the aortic ultrasound is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for an aortic ultrasound (76706) provided on March 3, 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: 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 enrollee has a complex health status and needs continued ventilation. This would be best provided in the LTACH setting. The Plan denied your request. The Plan says the enrollee's mental status is compromised and would make transfer to the LTACH unfeasible.
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 patient is currently undergoing treatment at an acute care hospital (ACH) following a massive stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator and does not appear to be tolerating ventilator weaning. The enrollee appears to have a poor overall prognosis. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute care and does not require 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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from March 4, 2020 to March 9, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per day for days 1-7 for in-network Medicare-covered hospital stays. You have been asked to pay a $225 copayment per day for days 1-5 for the inpatient hospital stay. ($225 x 5 = $1,125). The inpatient hospital 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 an inpatient hospital stay provided from March 4, 2020 to March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown for tooth #15. 
 
You asked the Plan to pre-approve the crown for tooth #15. You say that you lost your crown and need a 
replacement. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 years. 
 
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 also have a maximum benefit of 
one crown per tooth every 5 years. The Plan paid for a crown for tooth #15 provided on January 4, 2019, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth 
#15.