Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).

You asked the Plan to pre-approve the total electric hospital bed. You say that you need the fully electric bed because the partial electric bed does not rise up and down and you need a bed that rises up and down. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99217) provided on March 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management service is payable per patient per hospital stay. 

We looked at the file and Medicare rules. The records show that a separate hospital discharge day management code (99238) was billed on the same date of service by the same provider as the code in question. This service was paid by the Plan. This means that the requested hospital discharge day management code (99217) is not payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99217) provided on March 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from September 28, 2020, through October 30, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says authorization was not obtained.

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 physical therapy services. 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 physical therapy services provided from September 28, 2020, through October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided by an out-of-network provider on January 7, 2021.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that your notes did not indicate you needed a referral before choosing a specialist. You say that you tried to follow the necessary steps to get treatment coverage and the charge should be removed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 for the psychiatric diagnostic evaluation provided by an out-of-network provider on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for ophthalmological services provided on October 22, 2020.
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request. The Plan says the correct copayment was applied to the claim per the Plan's vision 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). Your contract with the Plan clearly says that you must pay $35 copayment for vision care. You have been asked to pay $35 copayment for the ophthalmological services. The ophthalmological services fall within the vision 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 waive the copayment for ophthalmological services provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with nausea, vomiting, dizziness, and ataxia. Magnetic resonance imaging (MRI) of the brain showed a cerebrovascular accident. The therapy notes show she needs minimal assist for bed mobility and maximal assist for transfers and shuffling two feet. She does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, 15 hours per week of rehabilitative services with and regular physician evaluation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound services you received from October 15, 2020, to October 28, 2020.

You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the costs share.

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 $110 copayment for each Medicare-covered radiological diagnostic service. 

Review of the file shows that you received three ultrasound services from October 15, 2020, to October 28, 2020. Per your contract with the Plan, there is a $110 copayment for each ultrasound service. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for each of these services was $80.22, $61.88, and $108.45. Given that each allowed amount was less than the $110 copayment, you have been asked to pay a total of $$250.55 for these services. 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 ultrasound services you received from October 15, 2020, to October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abdominal lipectomy (fat/skin removal) and lipectomy of the arms.

You asked the Plan to pre-approve the excess skin removal surgeries. You say that you believe that this service is medically necessary and should be covered. The Plan denied your request. The Plan says you do not meet the criteria for these procedures. They are considered cosmetic in nature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Specifically, for abdominal lipectomy, it is noted that a certain size of the excess skin must be evident as well as skin conditions which have resisted up to three months of conservative treatments. 

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 excess skin removal surgeries. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 59-year-old man for whom lipectomy of the arms and panniculectomy of the abdomen are requested. In this case, the enrollee underwent gastric bypass in November 2019. The physical examination does not indicate any evidence of intertrigo or that the pannus extends to the level of the pubis. Photographs were not submitted. Without any evidence of skin conditions related to the excess skin, the elements of the coverage criteria are not satisfied.

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 excess skin removal surgeries have not been met. Therefore, we decided that the Plan does not have to pre-approve abdominal lipectomy (fat/skin removal) and lipectomy of the arms.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 5, 2020.

You asked the Plan to waive the copayment for the urgent care visit. You say that you went for a Covid test and thought the copays would be waived. The Plan denied your request. The Plan says there was no cost sharing assessed for the Covid test, but you were charged the copayment for the visit 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 $65 copayment for Urgently Needed Services. 

You have been asked to pay a $65 copayment for the urgent care visit. the urgent care visit falls within the Urgently Needed Services 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 urgent care visit provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 14, 2020, and October 20, 2020 by an OON provider.

You asked the Plan to pay for the dental services. You say that you would like to be reimbursed the $1,000 benefit maximum you are allowed. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered when they are received by in-network dentists.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 14, 2020, and October 20, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you had on December 11, 2020.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you had on December 11, 2020.
Benefits for the vaccine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on October 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

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. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of services.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the crown
repair (D2980), and the root canal (D3330) provided on December 24, 2020.
You asked the Plan to reimburse you for the oral evaluation, crown repair, and root canal. You say that you
needed dental care on an emergency basis on Christmas Eve. You say that there was only 1 emergency dentist
available to see you. You say that you paid $1,868 with the understanding that you would be reimbursed for the
services. You say that the services should have been reimbursed at 100%. The Plan denied your request. The
Plan says limited oral evaluation is not listed as a covered service. The Plan says that crown repair is not listed
as a covered service. The Plan says that root canal is not listed as a covered service either.
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 reimburse you for
the limited oral evaluation (D0140), the crown repair (D2980), and the root canal (D3330) provided on
December 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the transport chair services provided from
January 12, 2020, to February 8, 2021.

You asked the Plan to waive the cost share for the transport chair. You say that the enrollee is being billed for a
chair she owns. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for durable medical equipment.

The enrollee has been asked to pay a 20% coinsurance for the transport chair. The chair falls within the durable
medical equipment benefit category. This means that the enrollee has been asked to pay the correct amount
based on her contract with the Plan. This cost sharing is a contractual obligation she agreed to pay when she
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the transport
chair services provided from January 12, 2020, to February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 30, 2020.

You asked the Plan to pay for the home visit. You say that the doctor depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the doctor should not be penalized, and payment should be reconsidered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 for the home visit provided by an out-of-network provider on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to transfer to the LTACH to regain maximum function and he will require another 3 to 4 weeks for ventilator weaning and transitioning from acute illness. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services required at the LTACH that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 18, 2020, by an OON
provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied
your request. The Plan says no prior authorization was obtained.

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 for the office visit provided on June 18, 2020, by an
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on November 20, 2020, to November 25, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should have been discharged on the 24th. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $85 copayment per day for days 1-10. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $85 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $85 x 4 days = $340). The correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided on November 20, 2020, to November 25, 2020.