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

We decided that the Plandoes not haveto pre-approvedrugs, supplies and materials received outside of the country on September 17, 2019.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approvedrugs, supplies and materials received outside of the country on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 8, 2019.
You asked the Plan to pay for the services provided. You say that the claim was filed in a reasonable time. The Plan denied your request. The Plan says the claim was received past the allowed time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services provided was not filed until March 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on June 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forspecialist services. You say that you were told that this provider was in-network.The Plan denied your request. The Plan says prior authorization was not obtained for the out-of-network provider.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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forspecialist services provided on June 11, 2020 by an out of network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional routine transportation trips.You asked the Planto pre-approvethe additional trips. You say that you have run out of trips but have no other way to get to your appointments. You feel that the plan should allow additional trips.The Plandenied your request. The Plansaysyou have used up the 48 trips allowed by your contract. No further trips are covered.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plandoes not haveto pre-approveadditional routine transportation trips
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 an LTACH admission does not appear to be appropriate for
this member based on the members current condition.
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 patient
appears to have a poor prognosis and would not require long-term acute care based on the provided notes.
Additional short term acute care services and coordination can safely be completed at the current facility. The
patient does not require services at the LTACH that are not already available at the current facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown repair necessitated by restorative material failure (D2980) provided on August 6, 2020.You asked the Plan to pay forthe crown repair necessitated by restorative material failure. You say that the service provided was necessary.The Plan denied your request. The Plan says this service is not covered under the Plan's supplemental 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 forthe crown repair necessitated by restorative material failure (D2980) provided on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness after a prolonged hospitalization for COVID 19 pneumonia. You were treated for a urinary tract infection. Your medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonableexpectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) scan services.You asked the Plan to pre-approvethe CT scan. You say that you need the requested CT scan of your leg because you are in a lot of pain and cannot walk straight. You say that you have to hop.The Plan denied your request. The Plan says they did not receive the results of a plain x-ray that failed to show the enrollee's doctor what they needed in order determine treatment.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 the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee sustained a fall approximately 5 years ago where she injured her right leg. Since that time, she has had a large mass in her Upper Anterior Thigh. The physical exam does not describe the mass; i.e. no precise measurements, is it mobile or fixed, does it trans-illuminate, is it painful to palpation, does it interfere with range of motion. There is no imaging either ultrasound or plain X-ray. Without this appropriate documentation and prior imaging, medically necessity has not been established.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scan services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe sacroiliac (SI) joint injection procedure you had at an ambulatory surgical center on August 13, 2020.You asked the Plan to waive the copayment forthe SI joint injection procedure. You say that on previous visits, you did not have this high of a copayment.The Plan denied your request. The Plan says you were charged this copayment 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 for each visit to an ambulatory surgical center. You have been asked to pay a $300 copayment for the SI joint injection procedure. The medical records clearly show that you had this procedure at an ambulatory surgical center, so the SI joint injection procedure falls within the visits to an ambulatory surgical center 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 forthe sacroiliac (SI) joint injection procedure you had at an ambulatory surgical center on August 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee does not need any skilled services.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of x-rays (D0210) provided on June 1, 2020.You asked the Plan to pay forthe dental service. You say that your hygienist advised that you that your insurance would cover a full mouth series of x-rays.The Plan deniedyour request. The Plan says a full mouth series of x-rays is not a covered benefit. The Plan also says that the only x-rays that are covered are bitewing x-rays.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 forthe complete series of x-rays (D0210) provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Planhasto pre-approvea special power wheelchair (K0851, E1028, E0973, E2363).You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no qualifying diagnosis causing a mobility limitation.The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker, cane or manual wheelchair,and the patient is capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is medically reasonable and necessary. Our physician reviewer found you have a personal mobility deficit that impairs participation in mobility related activities of daily living. You have weakness and unstable gait. You cannot use a walker, cane, or manual wheelchair. There is documentation of diabetic peripheral neuropathy and lumbar radiculopathy with weakness resulting in ambulatory dysfunction.
We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have been met.Therefore, we decided that the Planhas to pre-approvea special power wheelchair (K0851, E1028, E0973, E2363)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on August 5, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you thought that copayments were waived due to the pandemic.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment per each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 copayment fora specialist visit provided on August 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit services coded 99285 provided on July 8, 2020.You asked the Plan to pay forthe emergency department visit services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with modifier CS. Modifier CS is to be added anytime an E&M visit results in COVID-19 testing to be ordered. Review of the file does not support that COVID testing was suspected or provided on the date of the emergency department visit. Based on this information, we decided that Medicare rules for coverage of the emergency department visit services have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department visit services coded 99285 provided on July 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on June 10, 2020.
You asked the Plan to pay for the custom fabricated abutment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the service provided is not listed as a covered service.
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
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from November 2, 2019, through November 7, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You submitted your bill for review.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 $300 copayment per day for days 1-5 for each Medicare-covered inpatient hospital stay.You have been asked to pay $1,497.62, which is less than the standard $1,500 copayment ($300/day x 5 days = $1,500) for the inpatient stay. The inpatient 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 forthe inpatient stay provided from November 2, 2019, through November 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the deductible  forwound  debridement  and office  visit provided  on August  4, 2020,August  11, 2020 and  September  15, 2020.You asked the  Plan to waive  the deductible  forthe wound  debridement  and office  visit.  You say  that if  your feet are not taken  care of  it  can lead to infections  and losing  your  toes. You  say that  these  claims  should  be paid.The Plan  denied  your  request.  The  Plan  says the  deductible  applied  correctly.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  your  deductible  is $750. This  is the  amount  you  have  to pay out-of-pocket before  we will  pay  our share  for your  covered medical  services.  Until  you  have  paid the  deductibleamount, you  must  pay the  full  cost of your  covered services.The  item  or service  you  asked the  Plan  to waive  the  deductible  for  falls  within  the "Podiatry  services"  benefit category.  The  Plan  has  followed  Medicare  rules  by clearly  disclosing  in  the  contract  that  your  $750 deductible applies  to podiatry  services.  This  cost sharing  is  a contractual  obligation  that  had not been  met  at the  time  the wound  debridement  and office  visit  were received  on August  4, 2020,August  11, 2020 andSeptember  15, 2020.Therefore,  we decided  that  the Plan  does not have to waive  the  deductible  forwound  debridement  and office  visit  provided  on August  4, 2020, August  11, 2020 and September  15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe unspecified preventive dental service (D1999) provided on May 18, 2020.You asked the Plan to pay the in network rate forthe unspecified preventive dental service. You say that your regular dentist is not able to perform periodontal work. You saythat you needed to see a periodontist for these services. You say that the closest in network periodontist to you was almost 100 miles away. You say that the services should be paid.The Plan denied your request. The Plan says the unspecified preventivedental service is not listed as a covered service.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 unspecified preventive dental service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate forthe unspecified preventive dental service (D1999) provided on May 18, 2020