Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on October 22, 2020, to December 16, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that these copayments should be waived due to Covid-19. The Plan denied your request. The Plan says the correct copayments have 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 $35 copayment for physician/practitioner services/in-network/providers services/specialist. You have been asked to pay a $35 copayment for each specialist office visit. The total amount you are being asked to pay is $140 ($35 x 4 visits = $140). The correct copayments have been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/in-network/providers services/specialist 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 specialist office visit provided by a participating provider on October 22, 2020, to December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from December 22, 2020 to December 29, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $300 copayment per day for days 1-6 for inpatient hospital care.
Review of the file shows that you received inpatient hospital care from December 22, 2020 to December 29, 2020. You have been asked to pay a $300 copayment per day for days 1-6 for these services, for a total of $1,800. These services fall 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 the inpatient hospital services rendered from December 22, 2020 to December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are not medically reasonable and necessary.
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 that 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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 15933 and 15952 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 15933 is excision, sacral pressure ulcer, with primary suture; with ostectomy. The definition of code 15952 is excision, trochanteric pressure ulcer, with skin flap closure.
We find that CPT codes 15933 and 15952 are not supported in the medical record. Specifically, there is no documentation of excision of a sacral pressure ulcer and ostectomy to support code 15933. There is no documentation of an excision of a trochanteric pressure ulcer with skin flap closure to support code 15952. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 1, 2020.
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 you recently had surgery and cannot take care of
yourself. The Plan denied your request. The Plan says your 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 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 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. The patient 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 patient 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are not medically reasonable and necessary.
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 that, based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care.
You asked the Plan to provide acute inpatient hospital care. You say that the enrollee is having difficulty with activities of daily living and needs total hip arthroplasty. The Plan denied your request. The Plan says there is no documentation to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient hospital services are met in this case. Our physician reviewer found the provided records did not describe an indication for inpatient services around this elective surgery. There was no expectation of a complex surgery or prolonged recovery. There was no evidence to suggest this patient would require hospitalization that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide acute inpatient hospital care.
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 cannot be optimally restored at any other level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 continues to receive acute care services at the current hospital. The records do not indicate that the enrollee requires acute care services which he requires and it not currently receiving that would be available at the LTACH.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on February 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 lumbar-sacral orthosis (LSO) rendered on February 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission to be provided by the requested outof-
network provider.
You asked the Plan to pre-approve the SNF admission to the requested out-of-network provider. The Plan
denied your request. The Plan says that your contract requires that you must receive care from in-network
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service
area or if the care cannot be provided with an in-network provider. There is no gap in the network and there is
no continuity of care identified.
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 a SNF admission to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spine fusion (22558), an insertion of spine fixation device (22845), and an insertion of interbody biomechanical device (22853).
You asked the Plan to pre-approve a lumbar spine fusion, an insertion of spine fixation device, and an insertion of interbody biomechanical device. You say that the requested services are necessary for the care of the enrollee. The Plan denied your request. The Plan says rules for lumbar fusion have not been met because the requested services are not medically reasonable and 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 a lumbar spine fusion, an insertion of spine fixation device, and an insertion of interbody biomechanical device.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of adequate conservative measures to include a recent 6 week trial of physical therapy for back pain. 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 lumbar spine fusion, an insertion of spine fixation device, and an insertion of interbody biomechanical device have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine fusion (22558), an insertion of spine fixation device (22845), and an insertion of interbody biomechanical device (22853).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Medial Branch Block procedure (64493).
You asked the Plan to pre-approve the repeat Medial Branch Block procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for repeat procedures to be covered, the enrolle must have had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary pain.
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 repeat Medial Branch Block procedure. Our reviewer says that the repeat injections are not medically necessary. Our physician reviewer found the degree and duration from the first set of Left Medial Branch Blocks is not documented. Greater than 80% pain improvement must be clearly documented before any further Medial Branch Blocks are performed. 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 repeat Medial Branch Block procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Medial Branch Block procedure (64493).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Continuous Positive Air Pressure (CPAP) machine supplies (A7029, A7028, A7030, A4604).
You asked the Plan to pre-approve the CPAP supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that for CPAP coverage to continue, there must be objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.
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 CPAP supplies. Our reviewer says that the requested CPAP supplies are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the symptoms of obstructive sleep apnea are improved using CPAP. The documentation does not indicate that the enrollee uses the CPAP at least 4 hours per night more than 70% of the time. Since the rules for continued coverage of CPAP have not been met, the additional supplies are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Continuous Positive Air Pressure (CPAP) machine supplies (A7029, A7028, A7030, A4604).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D5899, D5140, D7140, D5110) received February 24, 2021.
You asked the Plan to pay for the dental services. You say that you were told you had an additional $1,000 allowance for dentures. The Plan denied your request. The Plan says your $1,000 annual dental maximum has been exhausted.
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 payment is in excess of that which is covered under this benefit. The Plan has submitted evidence that you have exhausted the $1,000 annual maximum allowance. You are responsible for any amount billed over and above the $1,000 limit. Therefore, we decided that the Plan does not have to pay for the dental services (D5899, D5140, D7140, D5110) received February 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on January 7, 2021 and February 4, 2021.
You asked the Plan to waive the copayments for the specialist office visits. You say that you have 100% financial assistance and should not have the copayments. 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 $50 copayment for specialist visits.
You have been asked to pay a $50 copayment for the specialist office visit on each date of service. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for specialist office visits provided on January 7, 2021 and February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided May 16, 2020, to May 19, 2020.
You asked the Plan to pay for the inpatient care. You say that DRG 100 was correctly billed. The Plan denied
your request. The Plan says the record supports DRG 101 instead of DRG 100.
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 100, Seizures with Major Complication or
Comorbidity. 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 the inpatient care. Our
reviewer says that the correct DRG for this service was DRG 101. Our physician reviewer found that DRG 100
was not supported in the medical records. The more appropriate DRG was DRG 101, Seizures without Major
Complication or Comorbidity.
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 inpatient care provided May 16, 2020, to May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction (D7210) to be performed by an oral surgeon.
You asked the Plan to pre-approve a dental extraction by an oral surgeon. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says the requested service is not a covered benefit when performed by an oral surgeon.
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. The Plan covers a dental extraction by an oral surgeon when the services are performed by a participating general dentist. We looked at the file and Medicare rules. You have requested a dental extraction by an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of a dental extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental extraction (D7210) to be performed by an oral surgeon.