Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting additional routine transportation trips to get to your physical therapy office. The Plan denied your request. The Plan says you exhausted your benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at your request, the records in the case file, and the rules. The 31st trip and beyond is not a covered benefit. The health plan contract says that you are covered for up to thirty (30) one-way rides per year to other health care related locations (such as to the pharmacy or specialist appointments). Therefore, we decided that the Plan does not have to pre-approve fifteen (15) additional routine transportation trips.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 testing provided to the enrollee.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says that laboratory results have not been submitted for the billed date of service.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. There is a laboratory requisition and laboratory results showing that the COVID-19 test came back negative. This is in direct contradiction to their denial reason. Therefore, we decided that the Plan has to pay for COVID-19 testing provided to the enrollee.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0156).

You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the amount of time spent rendering the billed service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that for Medicare to consider coverage and payment for any item or service, 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.

In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes.

We find that CPT code G0156 is not supported in the record. Specifically, the documentation submitted does not include clinical information to confirm that Medicare coverage criteria have been met. There is no record of the amount of time spent rendering the billed service. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0156).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a urodynamic study.

You asked the Plan to pay for the urodynamic study. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases care you receive from an out of network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out of network provider. You, or your PCP must obtain authorization prior to seeking care.

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 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 a urodynamic study.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because
these services were medically necessary. The Plan denied your request. The Plan says the documentation did
not include an interpretation report or lab results for the billed test.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, 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. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, the record does not include lab results to
verify the billed test. Therefore, we decided that the Plan does not have to pay for the drug testing services
(80307 and G0483).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on June 13, 2020.

You asked the Plan to pay for the emergency department visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this is a duplicate service already paid for.

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, a claim for the same service for the same enrollee on the same date of services was previously paid, on July 14, 2020, to a physician in the same practicing group. The second claim submitted does not contain a modifier or documentation that indicates this was a separate and distinct service. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on June 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the chest x-ray does not demonstrate any concerning findings. There is no documentation that permits any risk stratification. The enrollee does not satisfy the elements of the coverage rule because medical reasonableness and necessity have not been demonstrated. Therefore, the requested service cannot be recommended. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92250, 92014).

You asked the Plan to waive the copayment for the medical eye exam. You say that there should be no copayment for a routine eye exam. The Plan denied your request. The Plan says the records show the service was a medical eye exam and not a routine eye exam. The correct copayment 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 $45 copayment for Medical Eye Exams.

You have been asked to pay a $45 copayment for the medical eye exam. 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 a medical eye exam (92250, 92014).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment beyond. You do not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment beyond. Daily skilled services are not required beyond. You do not require the services on an inpatient basis, only in a SNF setting beyond. Services in a long-term care facility on a part time basis appear appropriate in this case.

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 continuation of SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the orthotic was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that for a spinal orthosis to be covered, you must meet the Medicare criteria listed in the 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says these are not covered services.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care.

You asked the Plan to waive the copayment for the admission to an inpatient hospital facility. You say that hospital staff insisted you get into a wheelchair to be brought to your daughter's car so she could bring you to the emergency room of another facility. You say the wheelchair broke, which resulted in the injuries that required your inpatient admission. You say that because the hospital was responsible for the injuries, you should not be expected to pay for the resulting service. The Plan denied your request. The Plan says inpatient care was provided. Each time you are admitted to an inpatient hospital, you pay $200.

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 admission for inpatient hospital care.

You have been asked to pay a $200 copayment for admission to an inpatient hospital facility. 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 inpatient hospital care.

Your complaint about injuries resulting from Plan-contracted hospital equipment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 appears to be improving gradually but still requires only short-term acute care services that can be safely received at the current facility until feeding status is more stable for discharge to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, without significant benefit noted over the current facility for acute care, this request for LTACH services will be considered not medically necessary at this time until a more permanent feeding route is arranged. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on October 20, 2020.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the drug test. 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 a drug test provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds your benefits.

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, oral exams are limited to once per year. The record shows that you received a comprehensive oral evaluation, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling.

You asked the Plan to pay for the dental service. You say that you had a filling done. You say that your insurance only paid $9.60. You say that when you called the dental plan you were not told why so little was paid. You say also that fillings should be covered at 80%. The Plan denied your request. The Plan says you pay a 20% coinsurance of the covered plan allowance after the $100 annual deductible is met. The Plan says that the provider in this case is out of network. The Plan also says that you can get care from an out of network dental provider, but you may pay more.

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, there is a 20% coinsurance for fillings after the $100 deductible has been met. Additionally, out of network providers can bill you for the difference of the allowed amount and their billed amount. Therefore, we decided that the Plan does not have to pay for the filling.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal manipulative treatment (98943) provided on
April 16, 2020.
You asked the Plan to pay for the extraspinal manipulative treatment. You say that you would like
reconsideration because you were told a referral was not necessary. The Plan denied your request. The Plan
says this is not a Medicare covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for extraspinal manipulative treatment (98943) provided on April 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 26, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were directed by your surgeon's staff to go to the emergency room. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for in- and out-of-network emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 26, 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. The Plan denied your request. The Plan says there is no need for transfer to another LTACH.
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 physician reviewer found that the enrollee was admitted to the acute hospital for an ischemic stroke, requiring mechanical ventilation and tracheostomy. The member was discharged to an LTACH for ventilator weaning and therapy. He requires frequent suctioning to keep airway clear. He also has bilateral heel and sacral decubitus ulcers that require daily treatment. The enrollee does not require services at the LTACH that are not available at the LTACH where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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.