Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110), therapeutic activities (97530), and the neuromuscular re-education (97112) rendered by the out of network (OON) provider from November 4, 2019 to November 29, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider, without 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 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 therapeutic exercises (97110), therapeutic activities (97530), and the neuromuscular re-education (97112) rendered by the out of network (OON) provider from November 4, 2019 to November 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on December 3, 2019.
You asked the Plan to waive the copayment for these services. You say that you had a similar procedure and it had a specialist copayment. The Plan denied your request. The Plan says the copayment was 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 for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center.
Review of the file shows that you received surgical services in outpatient hospital on December 3, 2019. You have been asked to pay a $225 copayment for these services. These services fall within the for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center 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 outpatient surgical services rendered to you on December 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from October 1, 2019 to October 31, 2019.
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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that a HIPPS code is required for SNF services under the PDPM. We looked at the file and Medicare rules. The claims were not billed with the required HIPPS 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 skilled nursing facility (SNF) services rendered from October 1, 2019 to October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implant services.
You asked the Plan to pre-approve the dental services. You say that implants will help the enrollee's emotional
state and prevent more bone loss. The Plan denied your request. The Plan says the requested services are not
covered under the enrollee's benefit package.
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.
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental
implant services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for colonic irrigation (45399) provided from May 20, 2019 to July 29, 2019.
You asked the Plan to pay for colonic irrigation. You say that these services have been covered in the past. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that colonic irrigation cannot be considered reasonable and necessary. We looked at the file and Medicare rules. The service at issue is colonic irrigation, which is not considered medically necessary and is therefore not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of colonic irrigation have not been met. Therefore, we decided that the Plan does not have to pay for colonic irrigation (45399) provided from May 20, 2019 to July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has had transfusions. Therefore, the use does not meet the FDA indications or the LCD 36276 indications for the use of Retacrit. Due to the enrollee is still iron deficient by labs on April 7, 2020 and there are no documented transfusions, the requested use is not medically reasonable and necessary nor is it safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
You asked the Plan to pre-approve a power wheelchair. You say that a power wheelchair is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the enrollee's condition can be ameliorated by a walker, cane or manual wheelchair. The records show the enrollee uses a walker in the home. There is no indication of trial and failure of a manual wheelchair in the home. The enrollee indicates the need for a power wheelchair is more so for outside of the home rather than in the home. Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71046) provided on November 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 71046 is part of an edit pair with procedure code 32555. Procedure code 32555 is a column one code, and procedure code 71046 is a column two code. Procedure code 32555 has been paid for the date of service in question, which means that procedure code 71046 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 71046) provided on November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating hospital on December 9, 2019 to December 11, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted the second time because of complications from the first visit. You say that you would like this copayment waived. 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 $360 copayment per day for days 1-5. There is a $0 copayment per day for days 6-90 for inpatient hospital care. You have been asked to pay a $360 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $720 ($360 x 2 days = $720). When you are admitted to the hospital for separate complaints, separate copayments are applied; therefore, the correct copayment has been applied. An inpatient hospital 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 an inpatient hospital stay provided by a participating hospital on December 9, 2019 to December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 31, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records (signed by
the ordering physician) therefore, the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that Medicare may cover lab testing when ordered by
a treating provider.
We looked at the file and Medicare rules. The submitted documentation does not include a copy of an order
from the treating provider in this case. As such, the Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 31,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth services for teeth 12, 19, and 30, gingival irrigation for tooth 8, periodontal maintenance for tooth 8, topical application of fluoride, core build up for tooth 8, crown, and resin based composite services for tooth 4.
You asked the Plan to pre-approve these dental services. 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 a covered 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.
Review of the file shows that while your benefit provides coverage for up to 2 fillings and 2 simple or surgical extractions per calendar year, you were already approved resin based composite, coded D2335, D2393, and surgical removal of two teeth. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested topical application of fluoride, crown, core buildup, periodontal maintenance, and gingival irrigation services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical removal of erupted tooth services for teeth 12, 19, and 30, gingival irrigation for tooth 8, periodontal maintenance for tooth 8, topical application of fluoride, core build up for tooth 8, crown, and resin based composite services for tooth 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) and topical application of fluoride varnish (D1206) provided on October 22, 2019.
You asked the Plan to pay for the bitewings and topical application of fluoride varnish. You say that during your appointment you were told that your insurance did not cover fluoride treatment and you paid for the service out of pocket. You also say that the x-ray was either coded incorrectly or you received the wrong type of x-ray. The Plan denied your request. The Plan says these services are not covered by the Plan.
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 bitewings (D0274) and topical application of fluoride varnish (D1206) provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on December 4, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 27, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital services provided to the enrollee on December 4, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered on November 12, 2019 to November 15, 2019.
You asked the Plan to waive the copayment for these services. You say that you should not be charged for the third day of services. The Plan denied your request. The Plan says the copayment was 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 $320 copayment each day for days 1-5 for Medicare-covered inpatient hospital care.
Review of the file shows that you received three days of inpatient hospital services from November 12, 2019 to November 15, 2019. You were not assessed a copayment for the date of discharge on November 15, 2019. You have been asked to pay a $320 copayment each day for these services, for a total of $960. These services fall within the Medicare-covered 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 hospital services rendered on November 12, 2019 to November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the right knee orthosis and suspension sleeve provided on June 6, 2019.
You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that orthoses were medically necessary. The Plan denied your request. The Plan says the medical necessity was demonstrated only for a left knee orthosis and sleeve.
The Plan must follow Medicare rules. Medicare rules say that that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the right knee orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833RT) and suspension sleeve (L2397RT) have not been met. Therefore, we decided that the Plan does not have to pay for the right knee orthosis and suspension sleeve provided on June 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee has no one at home to help.
The Plan denied your request. The Plan says the enrollee no longer needs daily nursing or therapy 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.
Continued services beyond April 26, 2020 were requested for 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 continued services. Our physician reviewer found that the enrollee does not
have a complex wound care or other SNF level skilled nursing need beyond the last covered day. The enrollee
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the
last covered day. The skilled nursing or skilled therapy services (or a combination of these services) are not
needed on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on
an inpatient basis, in a skilled nursing facility setting beyond the last covered day. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8,
2019 through October 29, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not 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 hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the medical records provided indicate that the admitting physician expected the
enrollee's admission to span two midnights. Documentation does not support inpatient care medically necessary
starting October 16,2019. There were no advance interventions or complex medical conditions. Inpatient
services were not supported by the documentation.
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 hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2019 through October
29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an MRI provided by a participating medical center on November 14, 2019.
You asked the Plan to reduce the copayment for an MRI. You say that the Plan should pay a portion of this bill. 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 $250 copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital. You have been asked to pay $237.86 which is less than your copayment amount of $250 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/advanced imaging services/outpatient hospital 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 reduce the copayment for an MRI provided by a participating medical center on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from November 23, 2019 to
November 24, 2019.
You asked the Plan to pay for inpatient mental health care. You say that this should be paid because a Plan
provider advised you to go inpatient. The Plan denied your request. The Plan says services after November 22,
2019 were not medically necessary or authorized.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our reviewer
says that the criteria for coverage of inpatient mental health care have not been met. Our physician reviewer
found the records provided show that it was not expected you would improve in a reasonable period of time for
the dates in question as you did not have suicidal or homicidal ideation noted and denied any auditory or visual
hallucinations. You were compliant with treatment while not showing any acute threats to safety. It did not
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care
rather than a lower level of care beyond the dates in question as you did not have dangerousness to self or
others but were compliant with your treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health care from November 23, 2019 to November 24, 2019.