Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional physical therapy home health visits for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide
treatment or that the services can be safely and effectively performed only by a therapist beyond the completed
PT visits and the additional one PT visit which was approved.
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 Plan does not
have to pre-approve seven additional physical therapy home health visits for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray.
You asked the Plan to pay for the x-ray. You say that the service is not related to the hospice diagnosis. The
Plan denied your request. The Plan says that Medicare hospice benefits covers attending physician services and
all care unrelated to the terminal illness until the first day of the month following the month in which hospice
was revoked or discharged.
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. The record
shows the proof of hospice election. Therefore, we decided that the Plan does not have to pay for the x-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were seen for a
follow-up after you were recently discharged for the hospital. 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 $40
copayment for each covered visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical
record shows the office was for seborrheic keratosis, neurofibroma, exfoliative dermatitis, melanocytic nevi of
trunk, and lentigines.
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 specialist office visit.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services.
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the claims are being submitted with
inappropriate home health data to process and pay 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.
We find that the home health services are not supported in the record. Specifically, the record shows that a
claim was billed without the required FIPS code for the place of residence where the home health service was
delivered. Based on this information, we decided that Medicare rules for coverage of the home health services
have not been met. Therefore, we decided that the Plan does not have to pay for home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan.
You asked the Plan to waive the copayment for a CT scan. You say that you should only owe a $50 copayment.
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 $100
copayment for diagnostic radiology.
You have been asked to pay a $100 copayment for a CT scan. A CT scan 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 a CT scan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 1, 2019.
You asked the Plan to waive the copayment for an ultrasound. 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 a $100 copayment for diagnostic radiology. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 ultrasound provided on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services you received on October 9, 2019.
You asked the Plan to waive the copayment. You say that the drain didn't work. The Plan denied your request. The Plan says the procedure was performed and you are responsible for the cost share.
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 $500 copayment per visit for outpatient surgery. Review of the file shows that you were provided surgical services on October 9, 2019. You have been asked to pay a $500 copayment for the services. The services fall within the outpatient surgery 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 surgical services you received on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAmitiza capsules.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.ThePlan 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-approveAmitiza capsules.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hygienic lower leg prosthesis.
You asked the Plan to pre-approve a hygienic lower leg prosthesis. You say that the enrollee needs a hygienic lower leg prosthesis to use while bathing or showering. The Plan denied your request. The Plan says the enrollee has a prosthesis for walking and a hygienic lower leg prosthesis is a convenience item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a lower leg prosthesis. The lower leg prosthesis received in August 2019 serves the same purpose as a hygienic lower leg prosthesis. Therefore, we decided that the Plan does not have to pre-approve a hygienic lower leg prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee has regressed to the extent that she cannot care for self. The Plan denied your request. The Plan says the enrollee has no acute symptoms that require 24-hour care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued services beyond February 5, 2020 was 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 it did not appear that active treatment was taking place. The services were not reasonably expected to improve the enrollee's condition, or for the purpose of diagnosis beyond the date in question. This enrollee was treated under an individualized treatment plan found in the record. The records were supervised and evaluated by a physician. Based upon review the records provided the enrollee does not meet the criteria for continued acute inpatient mental health treatment for February 6, 2020, forward as she was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided on September 26, 2019.You asked the Plan to waive the copayment forthe ultrasound. You say that you were only there for 10 minutes. You say that this is a lot of money for a simple procedure.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 $100 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $66.06, which is less than the standard $100 copayment for the ultrasound. The ultrasound 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 forthe ultrasound provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bridge (D6740).You asked the Plan to pre-approvethe dental services. You say that you are unable to use partials or dentures because your gums are really irritated. You also say that you have a lot of discomfort.The Plan denied your request. The Plan says bridges are not a covered service.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, bridges are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea bridge (D6740).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 31 - August 3, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the services were provided in good faith. You say that the medical records provided support the inpatient level of care. The Plan denied your request. The Plan says that the clinical records do not show that the enrollee met the medical necessity criteria for an inpatient hospital level of care. The plan says that the enrollees needs could have been provided in an alternated care level such as observation status of Acute Nursing Facility. 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was evaluated in the emergency department on July 31, 2019, after having spent the night on the floor following a fall. Our physician reviewer found that the enrollee reported several days of weakness and blood in his stools. Our physician reviewer found that the enrollee's initial evaluation identified mild dehydration and rhabdomyolysis. Our physician reviewer found that, at the time of admission, it was reasonable for the treating providers to believe that two midnights of care would be required to further treat, evaluate and monitor the enrollee. Our physician reviewer found that the enrollee slowly improved and was discharged having received three midnights of care. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided July 31 - August 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the enrollee on August 20, 2019. You asked the Plan to pay for inpatient hospital care. You say that the claim denied as a duplicate in error. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. According to Medicare rules, the submitted code, 99233, was denied for exceeding the maximum number of times this procedure can be allowed on a single date based on the date of service, procedure code, provider Tax Identification number and physician specialty. Procedure code 99233 was denied because it was already paid, therefore we would not expect this code to be submitted more than once on single date of service. After the maximum number of times is reached, additional submissions of the procedure are not recommended for reimbursement. Therefore, the claim will remain upheld. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the enrollee on August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for the wound care services. You say that the services were rendered prior to obtaining authorization to avoid a delay in care. The Plan denied your request. The Plan says the documentation shows that no authorization was obtained, it was not an emergency service and there are network providers available for the deliveryof the service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvescaling in presence of generalized moderate or severe gingival inflammation (D4346).You asked the Plan to pre-approvethe dental service. The Plan denied your request. The Plan says the requested dental service is not listed as a covered service.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 dental service is not among those coveredunder this benefit.Therefore, we decided that the Plan does not have to pre-approvescaling in presence of generalized moderate or severe gingival inflammation (D4346).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinpatient behavioral health admission for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be managed in another setting.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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no command hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinpatient behavioral health admission for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLinzess for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is needed to treat the enrollee's Irritable Bowel Syndrome with constipation.The Plan denied your request. The Plan says that this medication is not covered under 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-approveLinzess for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveradiofrequency ablation (RFA) of the medial branch nerves.You asked the Plan to pre-approveRFA procedure. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that the enrollee's pain was reduced by at least 80% after the previous 2 injections.The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation procedures are only covered when dual medial branch blocks provide greater than 80% relief of primary pain.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 RFA procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested RFA procedure. Our physician reviewer found there are no studies that document diagnostic efficacy of intra-articular facet block then proceeding to radiofrequency ablation. Therefore, the requested procedure 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 RFA procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation (RFA) of the medial branch nerves.