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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 infection and weakness and was discharged to skilled nursing facility where physical therapy is provided. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility care provided from May 26, 2020, to June 24, 2020.

You asked the Plan to pay for skilled nursing facility care. You say that this provider is eligible to provide these services. The Plan denied your request. The Plan says that this provider is not certified for Medicare.

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 the provider of these services does not have the required Medicare certification, but has not provided sufficient documentation showing that this is the case. The Medicare provider search shows that the provider of the services at issue is enrolled in Medicare. Therefore, we decided that the Plan has to pay for skilled nursing facility care provided from May 26, 2020, to June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lipectomy (15877, 15879).

You asked the Plan to pre-approve the lipectomy. You say that the services are medically necessary. The Plan denied your request. The Plan says the lipectomy is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the lipectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found lipidema occurs when fat is distributed in an irregular fashion, typically in the buttocks and legs. The documentation does not support that suction-assisted lipectomy of the trunk and lower extremities is medically reasonable and necessary for the enrollee in this case. 

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 lipectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a lipectomy (15877, 15879).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 15, 2020.
You asked the Plan to pay for the ambulance services. 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 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. In this case, the file shows the enrollee received these services during
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we
decided that the Plan does not have to pay for the ambulance services provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for radiology services provided by a
participating provider on February 22, 2020.

You asked the Plan to waive the deductible for radiology services. You say that you do not agree with this
deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $975 deductible for outpatient diagnostic tests/in-network.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $975 deductible for outpatient diagnostic tests/in-network. This cost sharing is a contractual
obligation that had not been met at the time radiology services was received on February 22, 2020. The total
amount you are being asked to pay is $23.81. Therefore, we decided that the Plan does not have to waive the
deductible for radiology services provided by a participating provider on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 24, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a domiciliary or rest home visit provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says you had exhausted your annual maximum for
your 2019 supplemental dental benefit as the Plan had paid $1000 of your dental services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file, the Plan's contract and Medicare rules. The Plan covered up to $1000 as your annual
supplemental dental benefit limit for the 2019 benefit year. The file shows that the Plan had paid $1000 of your
dental services. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2470), core buildup (D2950), a limited problem-focused oral evaluation (D0140), and a periapical x-ray (D0220) provided on September 29, 2020.
You asked the Plan to pay for a crown, core buildup, a limited problem-focused oral evaluation, and a periapical x-ray. You say that you were told that these services would be covered. The Plan denied your request. The Plan says these services are not covered under your dental benefit.
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 a crown (D2470), core buildup (D2950), a limited problem-focused oral evaluation (D0140), and a periapical x-ray (D0220) provided on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.

You asked the Plan to pay for the paramedic intercept services. 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 rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit (99283).

You asked the Plan to pay for the emergency visit. You say that the claim has not been paid in full or under the
terms of the contract for the services provided to this patient. 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 until the first day of the month following the month in which hospice was
revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for emergency department visit (99283).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for radiology services provided by a participating provider on February 5, 2020.

You asked the Plan to waive the deductible for radiology services. You say that you do not agree with this. The Plan denied your request. The Plan says the correct deductible amount has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible for outpatient diagnostic tests. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time radiology services was received on February 5, 2020. The total amount you are being asked to pay is $45.60. Therefore, we decided that the Plan does not have to waive the deductible for radiology services provided by a participating provider on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided from May 8, 2020 to June 4, 2020.

You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says acupuncture services are not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the case file does not contain documentation that you received the acupuncture services for chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from May 8, 2020 to June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.

You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental code D7953.

You asked the Plan to pay for dental code D7953. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D7953 is not covered under the Plan's supplemental dental benefit.

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, dental code D7953 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental code D7953.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you do not agree with this copayment. You say that you would like full reimbursement for these services. The Plan denied your request. The Plan says the correct copayment has been 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 $0 copayment per day for days 1-20. There is a $160 copayment for each day for days 21-49 for skilled nursing facility. 

You have been asked to pay a $0 copayment per day for days 1-20. There is a $160 copayment for each day for days 21-28 for a skilled nursing stay. The total amount you are being asked to pay is $1,120 ($160 x 7 days = $1,120). A skilled nursing stay falls within the skilled nursing facility 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 a skilled nursing stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390).

You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that Medicare guidelines stipulate that coinsurance stops after the enrollee has paid for 36 months of a 5-year lease. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment. While Medicare Advantage plans are required to provide coverage for durable medical equipment, there is no provision within the rules which requires this coverage to conform to Original Medicare payment methods. Oxygen reimbursement being limited to 36 monthly payments is applicable only to Original Medicare beneficiaries. Your plan covers medically necessary oxygen with 20% coinsurance. The contract does not indicate that this is waived after a certain number of total payments for the equipment.

You have been asked to pay $15.04, or 20% of the Medicare-allowed amount of $75.22, for the rental of an oxygen concentrator. An oxygen concentrator falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for protective equipment or interim caries arresting medicament application.

You asked the Plan to pay for personal protective equipment (D1999) or interim caries arresting medicament application (D1354). You say that your insurance is the same so the Plan should pay this claim. The Plan denied your request. The Plan says these services are not covered.

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 protective equipment or interim caries arresting medicament application.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says it is not medically necessary for you to go to an out-of-network provider for the requested services. A network gap does not exist.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.

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 not covered.

The Plan must follow Medicare rules. The rules say that BRCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation. 

We looked at the file and Medicare rules. The file shows that the enrollee does not have a personal history of cancer associated with the BRCA mutation. 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 BRCA genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76775) provided at  an Outpatient Hospital Facility on August 12, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you should be charged a lower copayment. The Plan denied your request. The Plan says the copayment was 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 $100 copayment for each Medicare-covered diagnostic procedure and test in an Outpatient Hospital Facility. 

You have been asked to pay a $100 copayment for the ultrasound provided at an outpatient hospital facility. Ultrasounds fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound (76775) provided on August 12, 2020.