Persius/hicric huggingface dataset:
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 LTACH admission 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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of her toes/foot. The enrollee underwent amputation of several toes. She continues to receive wound care, antibiotics and rehabilitative services. 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 for knee orthosis (L5000) provided August 15, 2019.You asked the Plan to pay forthe orthosis. You say that the enrollee has only received on L5000 this year and Medicare allows 2 per year.The Plan denied your request. The Plan says the records show that this enrollee already received this same item from the same provider on August 7, 2019. The records do not include documentation to support the replacement of this brace was necessary due to loss or irreparable damage.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L5000) provided August 15, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fort he drug testing coded G0483 provided on October 7, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and(3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include an itemized individual drug sub-classes list that were ordered in each drug class panel including the mthodology. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hysterectomy provided on September
13, 2019.
You asked the Plan to waive the copayment for the hysterectomy. You say that this procedure was a same-day
operation and you did not spend the night in the hospital. You say you are requesting a review of the charges
since the high copayment will cause you financial hardship. 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 20%
coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient
hospital, including but not limited to hospital or other facility changes and physician or surgical charges.
You have been asked to pay $1,797.67 which is 20% of the allowed amount for the hysterectomy. The allowed
amount is $8,988.34. ($8,988.34 x 20% = $1,797.67). The hysterectomy falls within the "Outpatient Surgery
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers"
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 hysterectomy provided on
September 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the operating rooms services provided by August 14, 2019.
You asked the Plan to waive the copayment for these services. You say that you were never put in outpatient surgery. The Plan denied your request. The Plan says that the claim processed 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 $290 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $290 copayment for these services. These services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 operating rooms services provided by August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot leave your home
because the portable oxygen tanks are too heavy. The Plan denied your request. The Plan says you were
provided M6 portable oxygen tanks that meet your needs within your home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary
oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a
portable oxygen concentrator. Medicare only covers oxygen for home use. The Plan has stated they can provide
you with lighter portable tanks. Therefore, we decided that the Plan does not have to pre-approve a portable
oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on July 9, 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 for a lumbar-sacral orthosis (L0648) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReclast for the enrollee.You asked the Plan to pre-approveReclast. The Plan denied your request. The Plansays the enrollee has not had previous treatment with generic Reclast.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Reclast. Our physician reviewer found that the enrollee has osteoporosis. The provided medical records do not support that Reclast is medically reasonable and necessary for the enrollee over the generic form, Zoledronic acid. The provided medical records do not support that Reclast is safe and effective for the enrollee over the generic form.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to pre-approveReclast for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on May 30, 2019.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on May 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from October 24, 2018, February 27, 2019, June 26, 2019 and October 23, 2019.
You asked the Plan to pay for the psychotherapy 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, dialysis while temporarily out of the plan's service area 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 psychotherapy services provided from October 24, 2018, February 27, 2019, June 26, 2019 and October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis, the knee orthosis and suspension sleeve provided  on September 13, 2019.You asked the Plan to pay for the wrist hand orthosis (L3916), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses was not met.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 for the wrist hand orthosis, the knee orthosis and suspension sleeve provided on 13, 2019.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 therequest to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is morbidly obese and debilitated because of prolonged morbid obesity. The enrollee is currently athome, non-ambulatory and bed bound. She is requesting an admission to an IRF which is denied and she is appealing. She would like to improve her level of function and have bariatric surgery. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. Her prior level of function was limited and she was functioning at max assist l level. The enrollee is generally medically stable, with no recent neurological or orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. While she may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 16, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you thought that you were covered for 2 cleanings and care per year. You also say that you are struggling financially.The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitation had been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat 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 and prophylaxis are each limited to one procedure per calendar year. The record shows that you received a periodic oral evaluation and a prophylaxis on April 16, 2019 and your exam and prophylaxis benefits were then exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 1, 2016 to December 31, 2016.
You asked the Plan to pay for the skilled nursing services. You say that these services were medical because of the enrollee's diagnoses. The Plan denied your request. The Plan says this provider is not certified with Medicare and therefore, the services are not covered by the Plan.
The Plan must follow Medicare rules. The rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at 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 January 1, 2016 to December 31, 2016.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system.You asked the Plan to pre-approve a power wheelchair power seat elevation system. You say that the enrollee needs a power seat elevation system.The Plan denied your request. The Plan says power seat elevation systems are not considered primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipmentto be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not haveto pre-approvea power wheelchair power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approven on-diabetic custom shoes.You asked the Plan to pre-approvethe custom shoes. You say that you need the shoes due to your foot being broken down and infected.The Plan denied your request. The Plan says this item isnot a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvenon-diabetic custom shoes.
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 August 16, 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 August 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that an ambulance was called because you were having leg pain which caused you to pass out. You say that after the responders arrived, you regained consciousness and began to feel better. The responders checked your vitals and after determining that you were okay, you decided that you did not need transportation. You asked the Plan to pay for the services because the ambulance was called for an emergency.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 23, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.