Persius/hicric huggingface dataset:
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 enrollee needs this level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met as a lower level of care such as Skilled Nursing Facility or Sub-Acute Rehabilitation. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 3, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the entire procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27132 and 27355) provided on June 14,
2019.
You asked the Plan to pay for surgical services. You say that these codes are fully supported. The Plan denied
your request. The Plan says these codes are not supported for the date of service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 27132 and 27355 is not supported in the medical record. Specifically, these codes were
billed for June 14, 2019, but the operative note submitted states that the procedures were performed on June 13,
2019. Based on this information, we decided that Medicare rules for coverage of surgical services have not
been met. Therefore, we decided that the Plan does not have to pay for surgical services (27132 and 27355)
provided on June 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 21, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the gene panel is not covered.
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 looked at the file and the rules. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a patient's response to the medication. In this case, there were insufficient records to support that the provided pharmacogenetic testing was medically necessary or reasonable. 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 genetic testing provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on to the enrollee by an out-ofnetwork provider on January 30, 2020. 
 
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 on to the enrollee by an out-of-network provider on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D2330 and D2331) provided January 29, 2020 
 
You asked the Plan to pay for the dental services. You say that you received your insurance card in November stating that you had dental coverage and the dental office confirmed. Had you known this would not be covered in 2020 you would have scheduled in 2019. The Plan denied your request. The Plan says these services are not covered under the plan benefits. 
 
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. Services not listed under the Description of Benefit is not covered.  
 
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 fillings (D2330 and D2331) provided January 29, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967 and the normal saline solution infusion services coded J7040 provided on October 9, 2018.
You asked the Plan to pay for the low osmolar contrast material and the normal saline solution infusion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes Q9967 and J7040 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of the dosage administered of low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml; therefore, code Q9967 cannot be verified. Also, the documentation submitted did not include documentation of Infusion, normal saline solution, sterile (500 ml=1 unit); therefore, the code J7040 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material and the normal saline solution infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967 and the normal saline solution infusion services coded J7040 provided on October 9, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on July 24, 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 codes 64450 and 99152 are 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 64450 is injection, anesthetic agent; other peripheral nerve or branch. The definition of code 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT codes 64450 and 99152 are not supported in the medical record. Specifically, there is no documentation of an injection of anesthetic agents or steroid to support code 64450 and no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status to support code 99152. 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 injection services rendered on July 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on March 2, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you would like the copayment removed
for this follow-up visit 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 $50
copayment for each Medicare-covered x-ray at an in-network services in an outpatient hospital facility.
You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The record shows you were billed by an
outpatient hospital.
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 x-ray provided on March 2, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) services. 
 
You asked the Plan to pre-approve the LDCT services. You say that you have a spot on your lung and have an upcoming appointment. The Plan denied your request. The Plan says the criteria for coverage of a LDCT have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a LDCT to be covered, an enrollee must meet all of the eligibility criteria.  
 
We looked at the file and Medicare rules. One of the eligibility criteria that must be met for coverage of an LDCT is that the enrollee must be a current smoker or one who has quit smoking within the last 15 years. The records show that the enrollee is not a current smoker and quit smoking 36 years ago. Based on this information, we decided that Medicare rules for coverage of the LDCT services have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided February 12, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are in the process of getting a tooth implant and every dentist and surgeon billed have been denied. You are confused as to what is covered. The Plan denied your request. The Plan says enrollee's must receive services from a network provider. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
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. This provider has opted out of the Medicare program. The file shows that  entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on December 20, 2019.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered
benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers an eye refraction to determine changes in your vision and/or the need for eyeglasses
or contact lenses.
We looked at the file and the Plan's rules. The eye refraction you received was for medical purposes. The
refraction was not provided to determine changes in your vision and/or the need for eyeglasses or contact
lenses. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been
met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on December 20,
2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's ongoing care needs include respiratory support including nebulizer treatments, surveillance laboratory studies, total parenteral nutrition, wound care, ostomy care, and therapy services. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including nebulizer treatments, surveillance laboratory studies, total parenteral nutrition, wound care, ostomy care, and therapy services. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from October 14, 2019, to October
30, 2019.
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 that
has opted out of the Medicare program. The file shows that this provider entered into a private contract with
you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received
from October 14, 2019, to October 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services provided February 15, 2020. 
 
You asked the Plan to pay for the outpatient therapy services. You say that the enrollee had revoked their hospice benefit at the time services were rendered. The Plan denied your request. The Plan says Original Medicare is liable for payment. 
 
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 February 12, 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 outpatient therapy services provided February 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 3, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you are dissatisfied with the copayment amount requested for the specialist. 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 $40 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a specialist. 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 office visit provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing (NGS) provided on August 7, 2019.
You asked the Plan to pay for the NGS (81406 and 81479). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee is with a new primary cancer diagnosis. The file shows that the enrollee does not have either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, we decided that the Plan does not have to pay for the next generation sequencing (NGS) provided on August 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by an
in-network facility on March 12, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not think that
you should pay this for a follow-up visit. You say that times are hard right now. The Plan denied your request.
The Plan says the correct copayment has been applied to the services that were 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 outpatient hospital services/in-network.
You have been asked to pay a $225 copayment for outpatient hospital services. Outpatient hospital services
falls within the outpatient hospital services/in-network 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 outpatient hospital services provided by an in-network facility on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 7-month rental of a 4 PAP device with humidifier device.
You asked the Plan to pre-approve the DME. You say that the machine has significantly helped you and has totally improved your way of life. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. Based on the clinical information received, you only used your breathing device 27% of the required 70% in a 30-day period. Therefore, we cannot authorize this request at this time. Therefore, we decided that the Plan does not have to pre-approve an additional 7-month rental of a 4 PAP device with humidifier device.