Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are very weak and need to get back on your feet.
The Plan denied your request. The Plan says you are not able to take part in 3 hours of therapy a day, and does
not need an intensive team for 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 physician reviewer found
that you have worsening lung cancer, with no recent neurological or orthopedic events. There is no evidence of
complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need
for acute rehab nursing care. Functionally you require contact guard assist for mobility, and cannot tolerate IRF
level therapies. While you may benefit from continuing physical therapy, there is no evidence of need for an
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provide on September 26, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford to pay this. The Plan denied your request. The Plan says that the applicable cost-sharing 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 a $150 copayment for each Medicare-covered one-way trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip 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 ambulance transport provide on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the 3 additional surgical extractions (D7210) provided on September 4, 2019.
You asked the Plan to pay the in network rate for 3 additional extractions. You say that the enrollee was never advised that the provider was out of network. You say that the enrollee is on a fixed income. You also say that the enrollee was treated poorly by the provider. The Plan denied your request. The Plan says 6 extractions are covered per year. The Plan says the frequency limit for this benefit has been exceeded. The Plan also says that 2 refunds ($746 and $834) have been issued for the dentures that were completed and returned.
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 and extractions are a covered service, the frequency limit for extractions has been exceeded. The record shows that the Plan approved and paid the in network rate for 6 extractions that you received on September 4, 2019. Therefore, we decided that the Plan does not have to pay the in network rate for the 3 additional surgical extractions (D7210) provided on September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 5, 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 code 31645 is 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 31645 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. We find that CPT code 31645 is not supported in the medical record. Specifically, the records do not indicate that a bronchoscopy with therapeutic aspiration of thraceobronchial tree was performed. 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 services rendered to the enrollee on October 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 12, 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 80307 and G0480 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 80307 is presumptive drug testing, any number of drug classes. The definition of code G0480 is definitive drug testing, 1-7 drug classes. We find that CPT code is not supported in the medical record. Specifically, there is no documentation of the method of testing to support the billed codes. 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 drug testing rendered to the enrollee on April 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on July 18, 2019.
You asked the Plan to reimburse you for the immediate dentures. You say that you went to a dentist that was approved by your plan. You say that the approved provider referred you to another provider for the extractions and dentures. You also say that you cannot afford to not be reimbursed for at least part of the bill. The Plan denied your request. The Plan says immediate dentures are not 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 immediate dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 30, 2019 to November 3, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment per day for days 1-4, $0 for days 5-90 for inpatient hospital care.You have been asked to pay $800 for the inpatient hospital stay. $200 per day for 4 days' equals $800. 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 foran inpatient hospital stay provided from October 30, 2019 to November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6540.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are necessary because they reduce swelling in your legs. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6540 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6540.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the Neck (70491) provided August 14, 2019.You asked the Plan to pay forthe CT scan. You say that the service was medically necessary.The Plan denied your request. The Plan says payment for this procedure was bundled with payment for the primary procedure.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, we have confirmed that code 70491 has a bundled relationship with code 78815 (PETScan with concurrent CT) and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forComputed Tomography (CT) of the Neck (70491) provided August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided October 1 to October 7, 2019 by the Medical Center.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment should be waived because the admission resulted from the plan's denial of rehab services. The Plan denied your request. The Plan says the correct cost-sharing 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 a $195 per day copayment for days 1 through 7 of an inpatient stay. You have been asked to pay a $1,170 for 6 days of inpatient care. 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 inpatient hospital services provided October 1 to October 7, 2019 by the Medical Center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, no safety concerns or behavioral issues. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our doctor was unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression was found to be compliant and cooperative with treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your physician provided medically necessary services to your member in good faith and in consideration for the services rendered is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 items/services at issue in this appeal. 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 for the subsequent nursing facility care (99309) provided on September 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve photochemotherapy with UV-B treatments.
You asked the Plan to pre-approve these services. You say that you have skin problems with severe itching. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that ultraviolet B therapy is covered for the treatment of psoriasis. We looked at the file and Medicare rules. The file shows that the services are being requested for the treatment of severe pruritis. This is not a condition for which these services are covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve photochemotherapy with UV-B treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with the doctor.
You asked the Plan to pre-approve the visit with the doctor. You say that the doctor is the only provider in your area that can perform the surgery you need. The Plan denied your request. The Plan says there are in-network providers in your area that can provide the services at issue.
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 the consultation with the doctor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851).
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 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 orthosis. Our reviewer says that the documentation does not support medical necessity. Our physician reviewer found the submitted documentation does not a physical examination of knee instability. Without the supporting documentation, medical necessity is not determined. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness class provided February 1, 2019 to December 31, 2019.
You asked the Plan to pay for the fitness class. You say that you filed a claim for benefit reimbursement for a fitness facility membership and it was denied. You sent the completed application and receipts and do not understand why your claim does not qualify. The Plan denied your request. The Plan says enrollee's must go to a participating fitness facility for covered benefits.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when provided from a participating fitness facility. The Plan's rules for coverage of gym benefits have not been met because the services was provided by a non-participating fitness facility. Therefore, we decided that the Plan does not have to pay for the fitness class provided February 1, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there is no evidence of danger to self or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond March 12, 2020 were requested for 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 continued services. Our physician reviewer found that it did not appear that active treatment was taking place. The services were not reasonably expected to improve the enrollee's condition, or for the purpose of diagnosis. There is no evidence of individualized treatment. It did appear that the records were supervised and evaluated by a physician. Based upon review the records, the enrollee was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab therapy for strengthening, gait training, and adaptive equipment training. The Plan denied your request. The Plan says the enrollee is not able to participate in intensive therapy, and does not require an intensive team for 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 physician reviewer found that the enrollee is generally medically stable with Dysphagia and post PEG tube placement. He has no endurance for activity in physical therapy. He is at max assist for all mobility and activities of daily living. He has no recent neurological or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. While the enrollee may benefit from continuing physical and occupational therapy, there is no evidence that he can tolerate an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.