Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee is not able to sustain three hours of intensive daily therapy.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 physician reviewer found that the enrollee suffered a fall that caused a right femur fracture. She is weight-bearing as tolerated, and is hemodynamically stable. She is at moderate assist for mobility, toilet use, and activities of daily living. The complexity of the enrollee's nursing, medical, and rehab needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 7, 2019 to October 12, 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 meet Medicare guidelines for SNF continuation. The Plan also says that the enrollee did not require daily skilled nursing and/or daily skilled rehabilitation services.
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 October 7, 2019 to October 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 6,2020 by an OON provider.You asked the Plan to pay for the resin-based composites. You say that a Plan representative confirmed that the treating provider was listed as a contracted provider. You also say that further research showed that this provider is not a contracted provider.The Plan denied your request. The Plan says the treating provider is not a part of the Plan's network. The Plan also says that services done by an OON dentist 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 covered when they are received OON. The record shows that you were advised that this provider was not in network with your plan.Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on January 6, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac radio frequency joint ablation for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says this procedure for the treatment of SI-joint mediated pain is considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that 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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the S1-S3 lateral branches is considered experimental/ investigational because of the wide variation in efficacy reported in the peer-reviewed literature. Therefore, the request is considered not medically reasonable or necessary.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve sacroiliac radiofrequency joint ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wound care product
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that 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. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee sustained a closed fracture of the calcaneus. The enrollee is experiencing slow healing and the development of achilles tendinitis. The documentation does not indicate the enrollee has any open wounds. Review of the compendia does not support the use of this product for the enrollee's conditions. Without the support of the documentation, medical necessity cannot be determined. Therefore, the enrollee does not meet criteria for the requested wound care product. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a wound care product
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewings (D0274), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on January 16, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, periodic oral evaluation, and prophylaxis. You say that your EOC says that you have a $0.00 copay The Plan denied your request. The Plan says first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings are not covered benefits. The Plan also says that the treating provider is OON and the cost share was applied correctly for the periodic oral evaluation and prophylaxis.
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, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings are not among those covered under this benefit. The contract also says that you are responsible for a 20% coinsurance for dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewings (D0274), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on January 16, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this service is covered under your benefit package but exceeds the maximum count allowed per period.
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. You exhausted your benefit frequency limit, because you had the same services rendered on September 26, 2018. Your EOC states, D2740 - one (1) procedure per tooth every five (5) plan years. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740).
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 discitis/osteomyelitis. The enrollee is to receive a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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: Lab
Decision: Favorable

We decided that the Plan has to pay for 4Kscore testing provided on August 27, 2019.
You asked the Plan to pay for 4Kscore testing. You say that this testing was medically necessary and you are the only provided that performs this test. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for 4Kscore testing by an in-network provider. The file does not show that the plan provided notice that 4Kscore testing would not be covered. Under Medicare rules, this means 4Kscore testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for 4Kscore testing provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections provided on January 20, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that you weren't aware you couldn't receive shots in the office. You say that you were informed anything done in the office was covered by insurance. The Plan denied your request. The Plan says the coinsurance 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 20% of the plan-allowed amount for Medicare Part B-covered drugs from an in-network provider. You have been asked to pay $33.89, which is 20% of the allowed amount for the injections. The allowed amount is $169.56 (20% x $169.56 = $33.89). The 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 coinsurance for the injections provided on January 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided
January 13, 2020 to January 16, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital care 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 $275 copayment each day for days 1-7 for Medicare-covered hospital care. You have been asked to pay a $825 copayment ($275 x 3 days) for the inpatient hospital care provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided January 13, 2020 to January 16, 2020.
Your complaint about the hospital billing for unnecessary services provided 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 the medical services provided on October 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for the lab services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare HMO and services should be received from contracted providers, except when urgent or an emergency. 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 medical services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the provider should have verified the member's eligibility.
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 an office visit provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 based on the medical records provided there is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in a long term care facility with intermittent services appears to be more appropriate in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 physician services provided on July 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on February 4, 2020.You asked the Plan to pay for the ankle foot orthosis. 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 L1971 is ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment.We find that CPT code L1971 is not supported in the medical record. Specifically, the documentation submitted did not indicate that the provider discussed the need for the billed supply code. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis have not been met.Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and periodic oral evaluation
(D0120) provided on January 21, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you have gone to this
same dental location for many years and your insurance has always paid 100% of the charges. You also say
that none of the information provided to you states the Plan's limits on how much they will pay. The Plan
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that
the cost share was applied correctly per your plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for
the prophylaxis (D1110) and periodic oral evaluation (D0120) provided on January 21, 2020 by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 16, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on January 16, 2020.