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

We decided that the Plan does not have to waive the copayment for the breast biopsy provided on July 11,
2019.
You asked the Plan to waive the copayment for the breast biopsy. You say that you had a non-surgical biopsy.
You say that you want to know why there is an operating service charge. The Plan denied your request. The
Plan says the copayment 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 $300
copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital
facility or ambulatory surgical center.
You have been asked to pay a $300 copayment for the breast biopsy. The breast biopsy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The breast biopsy is considered a surgical procedure. 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 breast biopsy provided on July 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the spinal injections provided on June 14, 2019 and July 24, 2019.
You asked the Plan to waive the copayments for the spinal injections. You say that you did not have any surgery done. The Plan denied your request. The Plan says you have been charged 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 $225 copayment for each day of Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charged and physician or surgical charges. You have been asked to pay a $225 copayment for each of the spinal injections. The spinal injections fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the spinal injections are considered a surgical procedure.
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 copayments for the spinal injections provided on June 14, 2019 and July 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for PT services provided on June 6, 2018.
You asked the Plan to pay for the PT services. You say that the claim should be paid. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the PT services was not filed until June 13, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for PT services provided on June 6, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device (E0730) provided on October 8, 2019.You asked the Plan to pay for the TENS device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare guidelines as the required modifier is absent.The Plan must follow Medicare rules. Medicare rulessay that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code E0730 is not supported in the record. Specifically, this claim was submitted without the required modifiers. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for a TENS device (E0730) provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).You asked the Plan to pre-approvepartial dentures. You say that you are requesting reconsideration of the Plan's denial.The Plan denied your request. The Plan says partial dentures are covered once every five years; therefore, youhave exceeded the benefit allowance.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. We looked at the case fileandthe Planrules. Based on this information, we decided that the Plan's rules for coverage of partial dentures have not been met.Specifically, the Plan contract allows for one upper partial denture and one lower partial denture once every five years. You previously exceededthe allowable benefitas youreceived partial dentures on May 20, 2016.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plansaysyou are able to perform daily living activities independently, and medical conditions are stable.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions appear stable. There are no complex wound care needs. You do not require medical oversight of your condition at an acute hospital level of care. There is a primary rehabilitation diagnosis ofdebility which does not support the medical necessity of acute level rehabilitation. You are limited by debility and the severity of your comorbid medical conditions. You would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
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 requested admission to a LTACH is
medically necessary. 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
shortness of breath attributed to pneumonia, chronic obstructive pulmonary disease and congestive heart
failure. The enrollee is not intubated/ventilated. 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF admission. You say that you need daily wound treatment and that the assistedliving facility does not provide wound care daily and it's only done 2-3 times a week. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF 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 topre-approve the SNF admission. Our reviewer says that daily skilled services are notmedically necessary. Our physician reviewer found the documentation is insufficient to demonstrate that you require skilled nursing or therapy services on a daily basis in an inpatient setting (SNF), as there are no hospital records from your current hospital stay.Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the you do not require the necessary services on an inpatient basis in a skilled nursing facility setting. You do not meet severity of illness or intensity of service criteria on 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 admission have not been met. Therefore, we decided that the Plan does
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 would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided through home-based and outpatient 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrimix.You asked the Plan to pre-approveTrimix. You say that this is the only medication that works for you.The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D prescription drug plan.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 pre-approveTrimix.Benefits for Trimixmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on October 24, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you went to your own dentist who provided the treatment for $155 and the Plan would not pay for it. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 periodontal maintenance provided on October 24, 2019.
Your complaint about being unhappy with the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for hearing services. You say that you were out of town when you had a hearing test. You say that this lead to you needing a hearing aid. You say that you would like these services covered. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for hearing services provided on October 22, 2019 by an out of network (OON) provider.
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 requested admission to a LTACH is medically necessary. 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for shortness of breath. Therapy has been aimed at congestive heart failure, obstructive sleep apnea and obesity hypoventilation syndrome. The enrollee is not intubated/ventilated. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe breast prostheses and mastectomy bra provided on September 6,2019 by OONprovider. You asked the Plan to pay forthe breast prostheses and mastectomy bra. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the itemsat issue in this appeal. The Plan did not pre-approve the itemsat issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay forthe breast prostheses and mastectomy bra provided on September 6,2019 by OONprovider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 21, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you already paid a copayment for your services. The Plan denied your request. The Plan says there is a separate copayment applied for the CT scan; therefore, 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 $190 copayment for outpatient diagnostic tests/in-network/CT scan. You have been asked to pay a $190 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/in-network/CT scan 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 CT scan provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on October 21, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that this service was for one of two preventive exams that your plan offers twice yearly. You also say that the 2 exams in February of 2019 were not preventive exams. The Plan denied your request. The Plan says the benefits for this service had been satisfied and the frequency limitation had been exceeded.
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, exams are limited to two procedures per calendar year. The record shows that you received two dental evaluations in February 2019 and your exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the athletic shoes purchased on July 28, 2019 and September 3, 2019from OONprovider.You asked the Plan to reimburse you forthe athletic shoes. You say that you had a prescription and you purchased them for a very cheap price.The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network purchase.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. Bealls Department Store is not a Medicare certified supplier. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to reimburse you for the athletic shoes purchased on July 28, 2019 and September 3, 2019 from OONprovider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 5, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 5, 2019.