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

We decided that the Plan does not have to pay for the inpatient admission requested on February 8, 2020.
You asked the Plan to pay for the inpatient admission. You say that the enrollee was appropriate for inpatient admission. The Plan denied your request. The Plan says the enrollee is on comfort care only and does not need to be in the inpatient setting, Care until hospice referral can be provided in outpatient observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found in the case of this enrollee, plans for hospice consultation/care was planned at home for the 2/8/2020 date prior to arrival at the ED with shortness of breath. Following initial evaluation, hospice was ordered to evaluate the patient in the hospital. The patient and family opted for comfort care prior to admission, and no further acute care treatment was planned or ordered. The treating physician did not expect hospital acute care to last longer than two midnights considering the clinical situation and based on the records. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient admission requested on February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 11, 2019, April 8, 2019 and June 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on March 11, 2019, April 8, 2019 and June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not require more frequent care for vent management. The services could be delivered at an alternate level of care.
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 an acute care hospital (ACH) with pneumonia, a UTI and chronic pelvic osteomyelitis. The enrollee is ventilator-dependent at baseline due to multiple sclerosis. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain, minor procedure, (D9110) provided on November 13, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says the emergency pain treatment is not a covered service.
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 emergency pain treatment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain, minor procedure, (D9110) provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided on October 15, 2019.
You asked the Plan to pay for the unspecified adjunctive procedure. You say that you just had a standard cleaning. The Plan denied your request. The Plan says the unspecified adjunctive procedure is not a covered service.
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 unspecified adjunctive procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) for all 4
quadrants provided from September 18, 2019 to October 9, 2019.
You asked the Plan to pay for the dental services. You say that you were advised you needed these services
prior to having your surgery. The Plan denied your request. The Plan says periodontal scaling and root planing
is not a covered service.
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 periodontal scaling and root
planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the periodontal scaling and root planing (D4341) for all 4 quadrants provided from September 18, 2019 to
October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 4, 2019.
You asked the Plan to pay for the physician's services. 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 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 physician's services provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on September 12, 2019.
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.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forremoval of growth of the scalp, neck, hands, feet, or genitals (11426), and removal of spermatic cord growth (55520) provided on October 22, 2019.You asked the Plan to waive the copayment forremoval of growth of the scalp, neck, hands, feet, or genitals, and removal of spermatic cord growth. You say that your doctor was to remove a lump from the right side of your groin. The lump was not removed. You wokeupfrom the procedure and you had an incision on your left sideinstead of your right side. You feel that your doctor does not deserve to be paid.The Plan denied your request. The Plan says outpatient procedures, surgical services, and other medical care provided by the primary care physicianhave a $40 copayment. The Plan also says that outpatient procedures performed in an ambulatory surgical center have a $100 copayment.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 $40 copayment for outpatient procedures, surgical services, and other medical care provided by the primary care physician. The Plan also says you must pay a$100 copayment foroutpatient procedures performed in an ambulatory surgical center. You have been asked to pay a $40 copayment for removal of growth of the scalp, neck, hands, feet, or genitals, and a $100 copayment for removal of spermatic cord growth. These servicesfall within the outpatient procedures, surgical services, and other medical care provided by the primary care physicianand outpatient procedures performed in an ambulatory surgical center benefit category($40 + $100 = $140). 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 forremoval of growth of the scalp, neck, hands, feet, or genitals (11426), and removal of spermatic cord growth (55520) provided on October 22, 2019.
Your complaint about the physicianand the procedureis 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 22, 2019 to September 20, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 22, 2019 to September 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99334) provided on July 16, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there are providers in-network that could render the services at issue. The services were not emergent or preauthorized.
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 the physician services (99334) provided on July 16, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 31, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 physician services provided to the enrollee on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cervical collar provided on September 16, 2019.You asked the Plan to pay forthe cervical collar (L0180). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrolleeand the ordering physician,and there is no valid Proof of Delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe cervical collar provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status (D0120), radiographic images (D0274), removal of plaque, calculus and stains from the tooth structures (D1110), and topical application of fluoride (D1208) provided on October 22, 2019 by out of network provider.You asked the Plan to pay foran evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status, radiographic images, removal of plaque, calculus and stains from the tooth structures, and topical application of fluoride. You say that you have been going to the physician for about 8 years. You have many health issues including heart issues and you trust him with your care. He knows all about your medical history. You just had a valve replaced on November 5, 2919 and you're just requesting that this claim be reconsidered. You don't trust any other dentists with all your health issues, and you've been to many other dentists and it's been a nightmare.The Plan denied your request. The Plan says it is important to know which providers are part of your network because, with limited exceptions, you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is notavailable (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.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 foran evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status (D0120), radiographic images (D0274), removal of plaque, calculus and stains from the tooth structures (D1110), and topical application of fluoride (D1208) provided on October 22, 2019 by out of network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance service provided on August 15,
2019
You asked the Plan to pay for the non-emergent ambulance service. You say that the transport was medically
necessary. 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the non-emergent ambulance service provided on August 15, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attended diagnostic polysomnography (PSG) (95810).You asked the Plan to pre-approvean  attended diagnostic PSG. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs could be met with a home sleep study.The Plan must follow Medicare rules. Medicare rules say that items and servicesthat are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an attended diagnostic PSG. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have a high suspicion for obstructive sleep apnea. The Epworth sleepiness score is normal. Symptoms are nonspecific. It is not clear from the medical record whether there is snoring. There are apparently no observed apneas. There is no assessment of upper airway patency or measurement of neck circumference. The patient does not have any conditions that would preclude a home PSG. A diagnostic, attended PSG is considered not medically necessary, and the denial is upheld. A home PSG may be an appropriate test for this patient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anattended diagnostic PSG have not been met.Therefore, we decided that the Plan does not have to pre-approvean attended diagnostic polysomnography (PSG) (95810).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the
abdomen and pelvis (74176) provided October 1, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that the copayments should be waived.
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 $175 for
Diagnostic Imaging.
You have been asked to pay $175 for the CT scan. The CT scan falls within the Diagnostic Imaging 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 Computed Tomography (CT) of the abdomen
and pelvis (74176) provided October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a wrist-hand orthosis (L3916)  provided to the enrollee on September 23, 2019.You asked the Plan to pay forthe 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 inan 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 likewisenoncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a wrist-hand orthosis (L3916)  provided to the enrollee on September 23, 2019.