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

We decided that the Plan does not have to pay for the acute inpatient hospitalization.
You asked the Plan to pay for acute inpatient hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is medically necessary.
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 acute inpatient hospitalization. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there was no clinical rationale for inpatient level of care services and the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospitalization have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospitalization.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve GenVisc 850 injections, bilateral knees.
You asked the Plan to pre-approve GenVisc 850, Hyaluronic Acid injections. You say that GenVisc 850 has a higher safety and efficacy results and the enrollee wants to avoid surgery. The Plan denied your request. The Plan says that the enrollee does not meet Plan criteria.
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 GenVisc 850, Hyaluronic Acid injections. Our reviewer says that in this case, the enrollee has x-ray evidence of a documented diagnosis of bilateral knee osteoarthritis, consistent with moderate to severe osteoarthritis. Our physician reviewer found the enrollee has tried and failed conservative therapy. The review has determined that the documentation supports that the GenVisc 850 is medically reasonable and necessary for the patient. The documentation supports that the GenVisc 850 is safe and effective for the 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 GenVisc 850, Hyaluronic Acid injections have been met. Therefore, we decided that the Plan has to pre-approve GenVisc 850 injections, bilateral knees.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you improve at a hospital but not at all at a nursing facility. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 you continue to receive acute care services that have not been denied. The record does not indicate that the you require services that you are not currently receiving but which would be available at 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an MRI and does not have to waive the coinsurance for a Medicare Part B drug provided on March 24, 2021.
You asked the Plan to waive the deductible for an MRI and to waive the coinsurance for a Medicare Part B drug. You say that you should only owe a $75 copayment and were charged less in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for radiological diagnostic services. Your contract with the Plan also clearly says that there is 20% coinsurance for Medicare Part B prescription drugs. You received an MRI on March 24, 2021. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $434.74. You received a Medicare Part B drug on March 24, 2021. The allowed amount is $36 and 10% of that is $3.60. The total amount you owe is: $438.34. The item or service you asked the Plan to waive the deductible for falls within the benefit categories: outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B prescription drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for radiological diagnostic services and 20% coinsurance for Medicare Part B prescription drugs. This cost sharing is a contractual obligation that had not been met at the time an MRI and a Medicare Part B drug were received on March 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an MRI and does not have to waive the coinsurance for a Medicare Part B drug provided on March 24, 2021.
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 enrollee is at risk for further injury and disability being at home The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic diagnostic imaging (92133) provided on April 27, 2021.
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 service 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 $10 copayment for x-rays, laboratory, and other diagnostic tests for each category per service date. You have been asked to pay a $10 copayment for the diagnostic service 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 scanning computerized ophthalmic diagnostic imaging (92133) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive or reimburse the 30% coinsurance charged for out of network Continuous Positive Airway Pressure (CPAP) rental from April 3, 2020, to December 3, 2020.
You asked the Plan to waive this coinsurance. You say that you asked permission to purchase the CPAP system out right rather than leasing for the 13-month rental period. You stated the Plan advised that the DME equipment company indicated the Plan is requiring the 13-month rental. You also stated the DME company is advising that the Plan required the 13-mmonth rental and therefore is appealing the denial.
The Plan denied your request. The Plan says this coinsurance was applied based on the Plan contract agreement and the Medicare rules for rental versus purchase of this type of equipment. The Plan says the requested reimbursement total of $323.03 was denied correctly as the you are responsible for out-of-network coinsurance amounts for Durable Medical Equipment as outlined in the Plan contract. The Plan states that an Explanation of Payment and Explanation of Benefits were mailed to the provider and member. These documents describe the claim being denied for "MAD - Required documentation was not submitted". The provider reported that full rental payments were received from insurance and you over the 13-month rental period, and due to the 30% out-of-network coinsurance responsibility, no reimbursement will be made.
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 clearly outlines the Medicare requirements and the Plan requirements for renting versus purchasing durable medical equipment. Your contract with the Plan clearly says that you must pay 30% coinsurance for out of network durable medical equipment. Based on review of the records and the submitted claim documentation 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 or reimburse the 30% coinsurance charged for out of network Continuous Positive Airway Pressure (CPAP) rental from April 3, 2020, to December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2740 x2), two core buildups, including any pins when required (D2950 x2), endodontic therapy (D3320), and four periodontal scalings and root planings (D4341 x4).
You asked the Plan to pre-approve the crowns, core buildups, endodontic therapy, and scalings and planings. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two crowns (D2740 x2), two core buildups, including any pins when required (D2950 x2), endodontic therapy (D3320), and four periodontal scalings and root planings (D4341 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient dialysis provided by a participating provider on January 2, 2021, to January 30, 2021.
You asked the Plan to waive the copayment for outpatient dialysis. You say that you never had to pay for dialysis before. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for services to treat kidney disease/outpatient dialysis treatments. You have been asked to pay a 20% coinsurance of the allowed amount for each outpatient dialysis session. The total allowed amount per session is $649. The amount you are being asked to pay for each session is $129.80 ($649 x 20% = $129.80). The total amount you are being asked to pay is $1,687.40 ($129.80 x 13 sessions =$1,687.40). The correct coinsurance has been applied to the services that were provided. Outpatient dialysis falls within the services to treat kidney disease/outpatient dialysis treatments 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 outpatient dialysis provided by a participating provider on January 2, 2021, to January 30, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visit on April 20, 2021. We decided that the Plan does not have to waive the copayment for the office visit on March 15, 2021. You asked the Plan to waive the copayments for the office visits. You say that you have a receipt for the copayment for the services on March 15, 2021.
We decided that the Plan has to waive the copayment for the office visit on April 20, 2021.
Medicare rules say that when you have a surgery, certain associated services are considered to be part of the payment for that surgery. In other words, you cannot be charged extra for these services in addition to the surgery itself. Postoperative visits during the Medicare-approved postoperative period are considered part of the payment for the surgery itself. In this case, you had carpal tunnel surgery (procedure code 64721) on April 13, 2021. Medicare rules say that this surgery has a 90-day postoperative period. That means that you cannot be charged a copayment for postoperative visits with this doctor within the 90 days following surgery. That is why we find that the Plan must waive the copayment for the office visit on April 20, 2021.
We also decided that the Plan does not have to waive the copayment for the office visit on March 15, 2021.
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 $35 copayment for specialist office visits. Medicare rules state that preoperative visits are only included in the cost of the surgery if the visit occurs within one day of the surgery itself. Since this visit was nearly a month before the surgery, a copayment was applied correctly. Therefore, we decided that the Plan does not have to waive the copayments for the office visit on March 15, 2021. Please note that we understand that you may have already paid this copayment to the provider. Please contact the provider directly if you are still receiving bills for a copayment that you already paid. That portion of your request is a grievance that we do not have jurisdiction to answer.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), and consultation (D9310) provided on March 19, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray, pulp vitality tests, and consultation. You say that the Plan advised that this was the only office with the correct provider that you should go to. The Plan denied your request. The Plan says these services are not covered. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), and consultation (D9310) provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow (Q4206).
You asked the Plan to pre-approve fluid flow. You say that the enrollee is in constant pain. You say that the enrollee is having a hard time with daily activities as a result. You also say that flow therapy is the best therapy because it is the only medication with the power to regenerate the tissue. The Plan denied your request. The Plan says there are not enough studies on amniotic fluid in the lung to show it is safe and effective. The Plan also says that the requested treatment is not approved by the FDA.
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 fluid flow. Our reviewer says that fluid flow is not medically necessary. Our physician reviewer found the provided documentation does not support that the fluid flow is medically reasonable or necessary for the enrollee. The reviewer found that flow fluid for knee pain is not approved by the Food and Drug Administration (FDA). The documentation does not support that the Fluid Flow is safe and effective for the enrollee. Therefore, the reviewer found that the requested treatment is 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 fluid flow have not been met. Specifically, the requested treatment is not approved by the FDA for knee pain. Therefore, we decided that the Plan does not have to pre-approve fluid flow (Q4206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381) and non-intravenous conscious sedation (D9248) for an upcoming dental procedure.
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 pre-approve localized delivery of antimicrobial agents (D4381) and non-intravenous conscious sedation (D9248) for an upcoming dental procedure.
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 enrollee continues to need daily physician care that cannot be managed at a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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 there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.