Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the deductible for these services. We decided that the Plan does not have to waive the coinsurance for these services. You asked the Plan to waive the deductible and coinsurance for these services. You say that you disagree with the charges. The Plan says that the cost sharing was applied correctly. We decided that the Plan has to waive the deductible for these services. 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 does not say in clear and accurate terms that there is a deductible for primary care doctor visits. The file shows that you received primary care physician services on October 18, 2019. The Plan applied a total of $86.30 to your deductible for these services; however, the contract does not clearly state that there is a deductible for primary care physician services. Therefore, we decided that the Plan has to waive the deductible for the primary care physician services rendered on October 18, 2019. We also decided that the Plan does not have to waive the coinsurance for these services. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a 20% coinsurance for each primary care doctor office visit. The file shows that you received primary care physician services on October 18, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the primary care doctor office visit benefit category. This cost sharing is a contractual obligation that you agreed to pay when you enrolled with the Plan.
This means that you have been asked to pay the correct amount based on the contract with the Plan. The file shows that your Medicaid coverage was not active for the date of service at issue, so the Medicare coinsurance was applied. Therefore, we decided that the Plan does not have to waive the coinsurance for the primary care physician services rendered on October 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says you could be treated at a lower level of care.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you do not have skilled therapy needs at this time, and while you do have skilled nursing needs, you do not need skilled nursing services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus palatinus (D7472), 3 removals of residual tooth roots (D7250 x3), 2 extractions of erupted tooth or exposed roots (7140 x2), and 20 extractions of erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x20) provided on December 27, 2019.
You asked the Plan to pay for the removal of torus palatinus, removals of residual tooth roots, and extractions. You say that these services were medically necessary. You also say that you assumed your dental plan would cover these needed procedures. The Plan denied your request. The Plan says your extractions benefit had been exhausted for the 2019 plan year.
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, removal of torus palatinus is not among those covered under this benefit. The contract also clearly states that simple or surgical extractions are limited to up to 2 per calendar year. The record shows that you received 22 extractions (D7210) on December 27, 2019, two of which were paid for, and your simple or surgical extractions benefit was then exhausted.
Therefore, we decided that the Plan does not have to pay for the removal of torus palatinus (D7472), 3 removals of residual tooth roots (D7250 x3), 2 extractions of erupted tooth or exposed roots (7140 x2), and 20 extractions of erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x20) provided on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 25, 2019 through August 27, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 25, 2019 and discharged on August 27, 2019. You were asked to pay a $285 copayment per day from August 25, 2019 through August 26, 2019, days 1-2 of your inpatient hospital care. You were discharged on August 27, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $285 copayment per day required for days 1-7. 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 care from August 25, 2019 through August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show active complex medical problems.
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 is currently undergoing treatment at an ACH for infected decubiti. The enrollee has received surgical debridement of her wound. She continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a safety belt/pelvic strap (HCPCS E0978)
You asked the Plan to pre-approve the item. You say that this is needed to help keep your pelvis aligned while seated in the wheelchair. The Plan denied your request. The Plan says a seat belt is already included with the power wheelchair.
The Plan must follow Medicare rules. The rules say that HCPCS E0978 cannot be billed separately from HCPCS K0861. A review of the file shows that K0861 - the power wheelchair itself - was requested and approved already. Payment for this code cannot be requested separately, and is included in the payment for HCPCS K0861. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve a safety belt/pelvic strap (HCPCS E0978).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound of the abdomen (76705) provided on October 31, 2019.
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration because the member had multiple services on the same date of service. The Plan denied your request. The Plan says this claim denied as a duplicate charge as this service had already been paid under another claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Specifically, this claim matches the member, provider, procedure code, date of service, quantity and billed amount of another claim that has already been processed and paid. The record does not indicate that a distinct, separate service was rendered. Therefore, we decided that the Plan does not have to pay for an ultrasound of the abdomen (76705) provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833), suspension sleeve (L2397) and addition to lower extremity orthosis (L2810) provided to the enrollee on September 24, 2019. You asked the Plan to pay for the orthoses and sleeve. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. We reviewed your records and they show that the enrollee was seen by your provider for a routine office visit. There is no mention in the records of any knee pain or instability. There is no mention of the need for knee bracing. The problem list in the medical record does not list knee pain as one of the enrollee's problems. There was no specific physical examination of the knee. Under Medicare guidelines, your request is not medically necessary because your records show the enrollee does not have an appropriate face-to-face encounter documented in the records to substantiate the need for these items. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833), suspension sleeve (L2397) and addition to lower extremity orthosis (L2810) provided to the enrollee on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dynasplint for the right shoulder.
You asked the Plan to pre-approve the Dynasplint. You say that the Dynasplit is medically necessary in order to provide a home exercise program for stretching and range of motion so that the enrollee is able to perform her functional daily activities once again. The Plan denied your request. The Plan says the device being requested is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Dynasplint. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the device in dispute is considered experimental. There is no decent literature that shows that the Dynasplint device improves outcomes of shoulder pathology and treatment when compared to conventional treatments. 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 Dynasplint have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dynasplint for the right shoulder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection on December 6, 2019 and December 7, 2019.
You asked the Plan to pay for these services. You say that you are confused by the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that 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 Plan does not have to pay for the insulin injection on December 6, 2019 and December 7, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment at a tertiary care facility.
You asked the Plan to pre-approve the treatment at a tertiary care facility. You say that the records provided support the need for a tertiary level of care. The Plan denied your request. The Plan says treatment in a tertiary care center is not required and that necessary care can be rendered by community level specialists.
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 treatment at a tertiary care facility. Our reviewer says that treatment at a tertiary care facility is not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not support a complexity of comorbidities, nor current clinical instability, that necessitates the enrollee receive surgical oncology care at a tertiary facility. Our physician reviewer found that care at a non-tertiary site for consultation and treatment is appropriate. 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 treatment at a tertiary care facility have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment at a tertiary care facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210), guided tissue regeneration (D4266), and an alveoloplasty not in conjunction with extractions for 1 to 3 teeth per quadrant (D7321).
You asked the Plan to pre-approve the guided tissue regeneration and alveoloplasty. You say that the enrollee needs a partial denture. You also say that before the enrollee can get a partial denture, the requested dental services need to be done. The Plan denied your request. The Plan says guided tissue regeneration and alveoloplasty for 1 to 3 teeth per quadrant are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), guided tissue regeneration (D4266), and an alveoloplasty not in conjunction with extractions for 1 to 3 teeth per quadrant (D7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cetuximab.
You asked the Plan to pre-approve Cetuximab. You say that the requested Cetuximab is medically necessary. The Plan denied your request. The Plan says the requested Cetuximab is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Cetuximab. Our reviewer says that the requested Cetuximab is not medically necessary. Our physician reviewer found the enrollee is diagnosed with stage IV colon cancer (rectal adenocarcinoma with mets to liver and lungs). The request is for Cetuximab. The requested use of Cetuximab is not FDA-approved for the enrollee's diagnosis. There is no data to support the use of Cetuximab after progression on panitumumab. The request for Cetuximab is not medically necessary for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cetuximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Cetuximab.
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 that LTACH is medically necessary. You
say that the enrollee is not capable of going home and in some cases has to be restrained. You say the enrollee
is able to participate in rehab and therapy. The Plan denied your request. The Plan says the requested admission
to a LTACH is not medically necessary.
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 that that the enrollee is currently undergoing treatment at an ACH. The enrollee is not
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 27, 2019 through December 3, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 27, 2019 through December 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided you received from an out-of-network provider from August 6, 2019, to December 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided you received from an out-of-network provider from August 6, 2019, to December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not
contain medical records for the date of service in question. Without these records, it cannot be determined that
Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the
services provided on September 9, 2019.