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

We decided that the Plan does not have to pre-approve inpatient mental health care after June 8, 2021.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says rules for inpatient mental health care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care.
Our reviewer says that inpatient mental health care is not medically necessary and reasonable. Our physician reviewer found that you are a 55-year-old male who was admitted to the acute inpatient psychiatric hospitalization on June 3, 2021 with Schizoaffective Disorder Bipolar Type. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with medication. Based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 8, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care after June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D5110, D5226) received January 6, 2021 from the out-of-network provider. You asked the Plan to pay for the dental services (D5110, D5226). You say that the requested services are necessary. The Plan denied your request. The Plan says dental services performed by an out-of-network provider are not covered. 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. The Plan does not provide coverage for services received out-of-network. Therefore, we decided that the Plan does not have to pay for the dental services (D5110, D5226) received January 6, 2021 from the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided November 22, 2020 to December 22, 2020.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover the SNF services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided November 22, 2020 to December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair provided on December 12, 2020.
You asked the Plan to waive the coinsurance for the manual wheelchair. You say that you should not be responsible for the coinsurance. 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 20% coinsurance for in-network Medicare-covered benefits.
You have been asked to pay $5.49 which is 20% of the allowed amount for the manual wheelchair. The allowed amount is $27.43. ($27.43 x 20% = $5.49). The manual wheelchair falls within the "Durable Medical Equipment (DME) and Related 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 coinsurance for the manual wheelchair provided on December 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient domiciliary, rest home or custodial care visit (99337) provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary, rest home, custodial care visit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 established patient domiciliary, rest home or custodial care visit (99337) provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on December 3, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on December 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance an
injection provided by a participating provider on November 30, 2020.
You asked the Plan to waive the copayment for an outpatient surgery and coinsurance an injection. You say
that you normally only pay a $100 copayment. You say that you received an additional bill for these services.
The Plan denied your request. The Plan says the correct charges have been applied to the services that were
provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for an outpatient surgery and a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $24.19 copayment for an outpatient surgery and a 20% coinsurance of the
allowed amount for an injection. The total allowed amount is $882.78. The total amount you are being asked
for an injection is $176.56 ($882.78 x 20% = $176.56). The total amount you are being asked to pay is $200.75
($24.19 + $176.56 = $200.75). The injection you received is considered an outpatient surgery; therefore, the
correct charges have been applied. An outpatient surgery falls within the outpatient surgery benefit category
and an injection falls within the Medicare Part B prescription drugs 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 outpatient surgery and coinsurance an injection provided by a participating
provider on November 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services rendered from July 15, 2020 to December 15, 2020.
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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that a marriage family therapist is not eligible to enroll in Medicare. We looked at the file and Medicare rules. The file shows that the provider is a licensed marriage family therapist (LMFT). 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 therapy services rendered from July 15, 2020 to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial imaging rendered on January 4, 2021.
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 services are not covered.
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 pay for the 2D oral/facial imaging rendered on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided on October 2, 2020.
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related accessories are not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the segmental gradient pressure pneumatic appliance have not been met.
Specifically, there is no evidence that the base PCD has been covered so the billed accessory is not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section1886(d)(1)(B)(iv)(I).  The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 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: 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 you need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been 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 that in this case, you were admitted to an acute care hospital due to altered mental status and sepsis due to COVID-19 infection. You are not clinically stable as you have ongoing pulmonary infection. You continue to receive acute critical care services that have not been denied. The medical records provided do not indicate that you require acute care services that you are not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied. 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 10, 2020.
You asked the Plan to pay for the laboratory services. You say that outpatient laboratory testing does not require a prior authorization. You say that the outpatient lab was medically necessary, and the services should be paid. The Plan denied your request. The Plan says prior authorization was not obtained prior to rendering services.
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 laboratory services provided by an out-of-network provider on December 10, 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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that you need to be seen by your doctors. The Plan denied your request. The Plan says additional trips exceed the benefit limit.
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. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 24,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you are being charged the full
copayment again and disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $30
copayment for specialist visits.
You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for extracapsular cataract removal provided on January 8, 2021.
You asked the Plan to waive the deductible for extracapsular cataract removal. You say that you were given misinformation and are being charged more money for the second surgery. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $500 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical enters. You received extracapsular cataract removal on January 8, 2021. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the deductible amount of $500. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical enters. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical enters. This cost sharing is a contractual obligation that had not been met at the time extracapsular cataract removal was received on January 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for extracapsular cataract removal provided on January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveIbrance cap 100mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medication was denied due to a benefit exclusion. 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 Plandoes not haveto pre-approveIbrance cap 100mg for the enrollee