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

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare criteria for transfer to an LTACH are not met.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 theenrollee does not have ongoing medical needs which require care in an 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered to the enrollee on July 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service (POS) code.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.The provider submitted a claim for procedure code 27197 (closed treatment of posterior pelvic ring fractures) with POS code 11 for an office setting. This code is on the inpatient only list and billing at the POS of 11 is not appropriate.Therefore, we decided that the Plan does not have to pay forthe surgical services rendered to the enrollee on July 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing services.You asked the Plan to pre-approvethe continued skilled nursing services. You say that due to the enrollee's disease, she is not able to progress at the rate the physicians anticipated. You also say that the enrollee is not able to get around independently and rely on the SNF staff to assistthe enrollee.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 22, 2019 to January 27, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 1, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership for the 2019 calendar year.
You asked the Plan to reimburse you for the health club membership. You say you need exercise for an injury to your lower legs and arms due to a fall and you are on a low income and you would like to be reimbursed for this health club membership. The Plan denied your request. The Plan says there is no flex benefit for the 2019 calendar year.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Your Plan does not offer a flex benefit for the 2019 calendar year. Therefore, we decided that the Plan does not have to reimburse you for a health club membership for the 2019 calendar year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services (88312) provided on October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory services. You say that you do not know who this provider is and you do not feel this is a bill you should have to pay. You don't recall signing a biopsy consent form.The Plan denied your request. The Plan says it was confirmed with the doctors office that you signed a Biopsy Consent Form on October 9, 2019 acknowledging responsibility of costs for services that were not covered or are out of network with the insurance carrier.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 networkprovider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The record shows that on October 9, 2019 you signed a Biopsy Consent Form. 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 forlaboratory services (88312) provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on October 1, 2019 and October 2, 2019.
You asked the Plan to waive the copayment for the office visits. You say that the test couldn't be performed so you had to stay overnight. You say that you shouldn't be charged if you were in the hospital. The Plan denied your request. The Plan says the copayments 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 $35 copayment for each specialist visit, including outpatient clinic visits. Covered services include, but are not limited to services in an emergency department or outpatient clinic, such as observation services or outpatient surgery. You have been asked to pay a $35 copayment for each office visit. The total amount you owe is $70 ($35/visit x 2 visits = $70). The office visits fall within the "Outpatient hospital services" benefit category. There is no provision in the contract which indicates a specialist visit copayment would be waived when admitted to outpatient observation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visits provided on October 1, 2019 and October 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says you are back to your prior level of function.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our physician reviewer found that your functional level does not require the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to be safely and effectively performed only by a therapist, or under the supervision of a therapist. You were educated in a home exercise program, and are able to demonstrate the program. The requested services do not need the knowledge and judgment of a qualified therapist to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 10, 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 G0482 and 80307 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 G0482 is definitive drug testing, 15-21 drug classes. The definition of code G0482 is presumptive drug testing, any number of classes. We find that CPT codes G0482 and 80307 are not supported in the medical record. Specifically, there is no documentation of results of drug classes tested. 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 on June 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the service is necessary.The Plan denied your request. The Plan says the requested service when used for clinical trials is not supported by Medicare guidelines.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 a CT scan of the abdomen and pelvis. Our reviewer says that the service is not medically necessary. Our physician reviewer found while it is completely reasonable to assess the enrollee for occult metastatic disease in the abdomen and pelvis since last CT was almost 6 months ago the NCCN guidelines do not support CT of the abdomen and pelvis without clinical symptoms and specifically the exam requested is not covered when part of a clinical trial.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 CT scan of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction of tooth #13 provided on October 4, 2019.You asked the Plan to pay forthe extraction of tooth #13. You say that you were misinformed as to whether or not this provider was in-network. You also say that you spoke with a plan representative and they told you that this provider was in-network.The Plan denied your request. The Plan says this service is not a covered 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, extractions are limited to two procedures per calendar year. The record shows that you receivedthree extractions on October 4, 2019, two of which the Plan paid for at the in-network rate, and your extractions benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe extraction of tooth #13 provided on October 4,2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you weren't aware of the network difference. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider without prior authorization.
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 medical services provided on June 24, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray (73523) provided on August 28, 2018.You asked the Plan to pay for an x-ray. You say that this was filed timely.The Plan denied your request. The Plan says this was filed more than a year after the date of service.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 claimfor an x-ray was not filed until October 16, 2019. 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 foran x-ray (73523) provided on August 28, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960) and knee orthosis (L1833) provided July 22, 2019.You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order, proof of delivery  or a delivery ticket for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960) and knee orthosis (L1833) provided July 22, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testing provided on October 16, 2019.You asked the Plan to waive the copayment forlab test. You say that this seems like a lot of money because you did not see any provider other than your primary care provider on this date of service.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 copayment for lab test. You have been asked to pay $20 copayment for lab test. Lab test falls 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 forlaboratory testing provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat right lumbar radiofrequency ablation (RFA) for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met because the enrollee did not have at least 50% pain relief for six months.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows the pain relief from the RFA lasted only 4 months, not the required (and expected) 6 months. Therefore, the request is deemed not medically reasonable or necessary. Therefore, the request is deemed not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat right lumbar radiofrequency ablation (RFA) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to stand, even with a walker. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for admission.
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 physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for a UTI with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at contact guard assist to standby assist for bed mobility and transfers. He requires varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. 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) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided September 6, 2019.You asked the Plan to pay forthe orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation does not include an itemized shipping/billing invoice to indicate the specific supplies were delivered to the enrollee. The submitted invoice states the items were shipped to Florida Med Group, LLC.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided September 6, 2019