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. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval for IRF admission.
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 the enrollee was medically stable with no evidence of need for supervision by PMR physician or needs acute rehab nursing care. He may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the elbow x-ray provided on September 5, 2019.
You asked the Plan to pay for the elbow x-ray. You say that your provider is not paid by hospice and is providing a service that is not related to hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the elbow x-ray provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 26, 2019.You asked the Plan to pay the full amount for the dental services. You say that the previous dentist that did your root canalbroke off a piece of equipment in your tooth. You say that this dentist took an x-ray to see what was going on and to determine the next step.The Plan denied your request. The Plan says they have reprocessed the claim to reflect payment of the services you received that day to up to the annual maximum. The Plan also says that the annual maximum coverage of $2,250 has been exceeded.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 cone beam CT is a covered service, the maximum allowance of $2,250 has been exceeded. The record shows that the Plan reprocessed your claim to show that the services you received on September 26, 2019 have been paid up to the maximum allowed amount.Therefore, we decided that the Plan does not have to pay the full amount forthe cone beam computed tomography(CT) capture and interpretation (D0364) provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit or the ear wax removal provided on July 19, 2019.You asked the Plan to waive the deductible forthe office visit and the ear wax removal. You say that the cost share is too high even though you knowit is correct. You say you will not pay this because you saw a nurse practitioner and not the doctor. 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 enrolleesin clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies towards in-network office visits and in-network surgical procedures. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The wax removal falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers."The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards in-network office visits and in-network surgical procedures. This cost sharing is a contractual obligation that had not been met at the time the office visit and the ear wax removal were received on July 19, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe office visit or the ear wax removal provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on August 29, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the charges.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 10% coinsurance for Part B drugs that are administered by a provider.You received the administration of a Medicare Part Bdrug on August 29, 2019. The allowed amount is $1,146.00 and 10% of that is $114.60. You have been asked to pay the total coinsurance amount of $114.60 for a Medicare Part B drug. A Medicare Part B drug 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 contractwith 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 fora Medicare Part B drug provided on August 29, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 30, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that copayments are a member's contractual obligation.
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 $200 copayment for per one-way ambulance trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 ambulance transport provided on September 30, 2019.
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 July 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 for the medical services provided to the enrollee by an out-of-network provider on July 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 21, 2019 to September 24, 2019.You asked the Plan to pay forthe skilled nursing services. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from April 24, 2019 to September 20, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 21, 2019 to September 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 16, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 17, 2019.
You asked the Plan to pay for the orthosis. 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 (L0650) provided to the enrollee on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the panoramic x-ray (D0330) provided on September 17, 2019.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says you are not a network provider with the Plan. The Plan also says that dental services provided 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, dental services that are provided by an out of network dentist are not covered.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), prophylaxis (D1110), andthe panoramic x-ray (D0330) provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor.You asked the Plan to pre-approvea Freestyle Libre sensor. You say that the item is 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. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 a Freestyle Libre sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found the plan requires that you be taking 3 shots of insulin per day to qualify for cgm; you are only taking 2 shots per day. You do not meet the criteria provided. This does not mean the cgm would not help you and make your life easier; however, given the criteria above you do not qualify for cgm.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre sensor have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre sensor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 26, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that this should be considered a screening colonoscopy. You say the motivation for ordering the test was routine, regardless of any findings from the colonoscopy 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 a $400 copayment for in-network Medicare-covered outpatient hospital surgery services. You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows a diagnosis code for abdominal pelvic pain which makes the colonoscopy diagnostic in nature.
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 colonoscopy provided on September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran outpatient hernia surgery provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay foran outpatient surgery. You say that you would like this claim to be considered for retro authorization.The Plan denied your request. The Plan says no prior authorization was obtained for these services. 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 thatthe Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran outpatient hernia surgery provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you are too weak to go home yet.The Plan denied your request. The Plan says that you do not require daily skilled therapies.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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forlaparoscopy provided from September 9, 2019 to September 12, 2019.You asked the Plan to waive the coinsurance forlaparoscopy. You say that you thought that you would owe inpatient charges.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 20% coinsurance for surgery performed at an outpatient hospital facility.The medical records show that you received laparoscopy from September 9, 2019 to September 12, 2019. This is considered an outpatient surgical procedure. The allowed amount is $7,504.85 and 20% of that is $1,500.97.  You have been asked to pay the total coinsurance amount of $1,500.97 for laparoscopy. Laparoscopy falls within the outpatient surgery, including services provided at hospitaloutpatient 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 coinsurance forlaparoscopy provided  from September 9, 2019 to September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 25, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says periodontal maintenance is covered 2 times per plan year. The Plan says that the frequency limit has been exceeded.
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 periodontal mainatenance is a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for this service for dates of service February 6, 2019 and May 23, 2019. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay for lab services (CPT 84166) provided to the enrollee on September 18, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe supporting documentation does not support CPT 84166, as it is a duplicate of a charge considered on a previous claim.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 84166 is "Protein; electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF)."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there are no records for the date of service in question or the service in question. Therefore, the billing of CPT 84166 on 9/18/2019 is not supported.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services (CPT 84166) provided to the enrollee on September 18, 2019.