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

We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the enrollee to be 
admitted to the LTACH to complete her treatment. The Plan denied your request. The Plan says the request for 
approval of admission to a LTACH does not meet the requirements for approval. 
 
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 necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she 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 Plan. Our physician reviewer also found that 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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve an interspinous spacer device. The Plan denied your request. The Plan says 
this is 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 an interspinous spacer device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that interspinous spacer devices remain experimental. More research is needed to 
show safety and efficacy of the device. Open laminectomy is the gold standard for spinal decompression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an interspinous spacer device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing.
You asked the Plan to pre-approve Cologuard testing. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered when the criteria in the applicable LCA are met. We looked at the file and Medicare rules. The records show that the enrollee is 90 years old. The LCA coverage criteria require the enrollee to be between 50-85 years old for coverage to be considered. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 550mg Xifaxan tablets. 
 
You asked the Plan to pre-approve Xifaxan. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this is not a covered benefit under Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 550mg Xifaxan tablets.  
 
Benefits for Xifaxan may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network
provider.
You asked the Plan to pre-approve physical therapy. You say that you have spinal injuries and want to be
referred to an out-of-network provider. The Plan denied your request. The Plan says there is an in-network
provider available.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physical therapy to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and cleaning (D1110) provided on 
May 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that the annual notice of change states that the 
amount of coinsurance for preventive services is to be paid for an out of network provider. You say that you 
were advised by a plan representative that 50% of your claim should be paid. You say that it is printed in black 
and white. You also say that the claim was denied for no out of network coverage. The Plan denied your 
request. The Plan says the provider in this case is out of network. The Plan says that dental services that you 
receive out of network 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 and the services are listed as covered, 
dental services that you receive out of network are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the oral exam (D0120) and cleaning (D1110) provided on May 
19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a participating provider on October 2, 2020, to December 31, 2020.
You asked the Plan to waive the copayment for telehealth services. You say that you were told that these copayments would be waived due to the pandemic. 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 a $20 copayment for physician/practitioner services/in-network. You have been asked to pay a $20 copayment for each telehealth service. The total amount you are being asked to pay is $80 ($20 x 4 telehealth services = $80). Telehealth services fall within the physician/practitioner services/in-network 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 telehealth services provided by a participating provider on October 2, 2020, to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on September 10, 2020.
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 were not reported with the appropriate diagnosis codes.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that procedure code 81235 and 81275 were not billed with an appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on October 1, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the fact that you are paying three times the amount the Plan is paying. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for MRI's. You have been asked to pay a $175 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 20, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a raised toilet seat.

You asked the Plan to reimburse you for a raised toilet seat. You say that you are unable to get off the toilet without assistance. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.

While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to reimburse you for a raised toilet seat.
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 the enrollee was treated in place and triaged to BLS. 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. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient services.

You asked the Plan to waive the deductible for the inpatient services. You say that this should have all been under the doctor's authority. You say that you do not have much money. The Plan denied your request. The Plan says the deductible applied correctly.

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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient services. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram and a diagnostic ultrasound provided by participating providers.

You asked the Plan to waive the copayment for a diagnostic mammogram and a diagnostic ultrasound. You say that you do not agree with both copayments. The Plan denied your request. The Plan says the correct copayments have 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 $30 copayment for outpatient diagnostic tests/in-network/diagnostic tests.

You have been asked to pay a $30 copayment for a diagnostic mammogram and a $30 copayment for a diagnostic ultrasound. The total amount you are being asked to pay is $60 ($30 x 2 tests = $60). A diagnostic mammogram and a diagnostic ultrasound fall within the outpatient diagnostic tests/in-network/diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram and a diagnostic ultrasound provided by participating providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a transforaminal epidural at an additional level (64484) provided on July 13, 2020.
You asked the Plan to pay for a transforaminal epidural at an additional level. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 64484 is injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure). We find that CPT code 64484 is not supported in the medical record. Specifically, the procedure note in the submitted medical records does not document that injections were performed on more than one level. Based on this information, we decided that Medicare rules for coverage of a transforaminal epidural at an additional level have not been met. Therefore, we decided that the Plan does not have to pay for a transforaminal epidural at an additional level (64484) provided on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care visits.

You asked the Plan to reduce the copayments for the wound care visits. You say that the services were rendered in a regular doctor's office and should only be responsible for a $40 copayment for each visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room, or outpatient surgery services. For each date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $275 copayment for the wound care visits.

You have been asked to pay a $138.76 copayment for the wound care on each date of service. ($138.76 x 3 days = $416.28). The wound care falls within the "Outpatient Hospital Services" benefit category. The record shows you were informed that the location of the wound care was considered hospital outpatient department services.

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 reduce the copayments for the wound care visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. 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. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have been receiving physical therapy treatments. The documentation does not support that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records, you appear to have improved with therapy to the point of being able to manage your activities of daily living and exercising in a gym with good strength and range of motion (though still with some pain). Further formal therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. Therefore, you do not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. The records show that a urine specimen was collected in this case. However, blood specimen collection is by Venipuncture. Based on the documentation submitted by the provider, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 10, 2020, through November 25, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you understood that copayments will be covered by the government. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per day for days 1-7 and a $0 copayment per day for days 8-90 for in-network, Medicare-covered hospital stays. You have been asked to pay a $1,575 copayment for the inpatient stay. ($225/day x first 7 days = $1,575). The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay provided from November 10, 2020, through November 25, 2020.