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 services are 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
You asked the Plan to pre-approve a Group 2 POV. You say that this is needed to get you around the home and outside of your home. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Group 2 POV will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 2 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for determination of refractive state (92015) provided to the enrollee on
February 6, 2020.
You asked the Plan to pay for the eye refraction. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says that you pay 40% coinsurance for an out-ofnetwork
provider for Medicare vision services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states this provider is in-network with your Plan; however, Original
Medicare doesn't cover routine eye exams (eye refractions) and they told you it was processed with your EOC
with 40% coinsurance. The EOC states that covered services include: Outpatient physician services for the
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular
degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts and
you pay 20% for out-of-network Medicare-covered vision services. Furthermore, the Plan did not notify us if
the provider participated with your supplemental vision plan network which this eye refraction would fall
under. Your EOC states that you pay any amount over $75 for an out-of-network routine eye exam (1 per
calendar year) eye exam will include refraction and dilation. Therefore, since the Plan did not provide accurate
information the request should be overturned for the eye refraction. Therefore, we decided that the Plan has to
pay for determination of refractive state (92015) provided to the enrollee on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to adjust the coinsurance for the eyewear provided on June 17, 2020.
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the eyewear provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.
Additionally, the rules say that Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says you must pay $91.20 for the eyewear provided. Based on the Plan contract however, payment in the amount of $200 should be issued for the purchase and fitting of eyeglasses at a network optical provider. The Plan allowed amount for the eyeglasses provided was $222.80 in which the $200 eyewear benefit applies. Your coinsurance responsibility is $22.80 ($222.80 Plan allowed amount-$200 benefit). Therefore, we decided that the Plan has to adjust the coinsurance from $91.20 to $22.80 for the eyewear provided on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on February 12, 2021.

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 Guardant360 testing rendered on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field eye examination (92083)
provided on February 11, 2021.
You asked the Plan to waive the copayment for a visual field eye examination. You say that your Plan does not
have any copayments for tests. The Plan denied your request. The Plan says you pay a $10 copayment for each
Medicare-covered visit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for vision care.
You have been asked to pay a $10 copayment for a visual field eye examination. The EOC confirms that $10 is
the required copayment for this service. A visual field eye examination falls within the vision 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 a visual field eye examination (92083)
provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 9, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that this is an annual wellness exam. You say that you should not have a copayment for this. 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 $50 copayment for physician/practitioner services/specialist visit.
You have been asked to pay a $50 copayment for a specialist office visit. The services that were provided went beyond an annual wellness exam. The provider who provided these services is considered a specialist; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 specialist office visit provided by a participating provider on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the $45 paid for compression stockings (A6533)
provided on January 6, 2021.

You asked the Plan to reimburse you for these compression stockings. You say that these compression
stockings were suggested after knee replacement and should be covered by the Plan. The Plan denied your
request. The Plan says compression stockings coded as A6553 are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing. The Plan contract says that
durable medical equipment may require prior authorization. This is important because the Plan would have
been able to work with your physician to order compression stockings that are covered by Medicare. Although
this item may be appropriate for your use, it is not covered by Medicare or the Plan. Therefore, we decided that
the Plan does not have to reimburse you $45 for compression stockings (A6533) provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), the oral hygiene instruction (D1330), bitewing x-rays (D0274), the periapical x-rays (D0220, D0230), and the fluoride varnish (D1206) provided on January 20, 2021, by the out-of-network dentist.
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was not contracted. You say that you cannot afford the extra expense. You also say that you were under the impression that you had full dental coverage. The Plan denied your request. The Plan says care rendered by a dentist this is not part of the Plan's supplemental dental network is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit when performed out of network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), the oral hygiene instruction (D1330), bitewing x-rays (D0274), the periapical x-rays (D0220, D0230), and the fluoride varnish (D1206) provided on January 20, 2021, by the out-of-network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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. The enrollee does not require services at the LTACH that are not available at the present setting 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 health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284).
You asked the Plan to pre-approve the dental item. Your provider says that the requested services are medically
necessary. The Plan denied your request. The Plan says up to $2,500 for comprehensive dental services. The
Plan also says that the maximum allowance has been reached.
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 removable unilateral partial denture
is listed as covered, the annual maximum benefit has been reached. The record shows that the Plan paid $165
for dental services that you received on January 21, 2021. The record also shows that the Plan approved 4
crowns and partial lower denture that total $2,335. $165+$2,335=$2,500. Therefore, we decided that the Plan
does not have to pre-approve a removable unilateral partial denture (D5284).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for physical therapy provided from January 18, 2021, through February 19, 2021.
You asked the Plan to reimburse an additional amount for physical therapy. You say that you paid $1,680 up front and are not ok with the refund that was received. The Plan denied your request. The Plan says the claim reimbursed correctly based on the allowed amount of the services.
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 out-of-network Medicare covered physical therapy visits.
The Plan reimbursed you $839.73 based on the allowed amount of the physical therapy services. The allowed amount is $1,359.73. You are responsible for a copayment amount of $40 for each physical therapy visit. ($40/visit x 13 visits = $520). ($1,359.73- $520 = $839.73 total reimbursement). Physical therapy falls within the "Outpatient rehabilitation services" benefit category. This means that you have been reimbursed the correct amount by the Plan. Therefore, we decided that the Plan does not have to reimburse an additional amount for physical therapy provided from January 18, 2021, through February 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the addition routine transportation (A0120).
You asked the Plan to pre-approve the addition routine transportation. You say that the service is medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan benefit for routine transportation.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the addition routine transportation (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health services provided from November 3, 2020, to November 13, 2020.
You asked the Plan to waive the copayment for the inpatient mental health care. You say that the cost of the services is too high for seniors on a limited income. The Plan denied your request. The Plan says the cost-sharing 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 $300 copayment for each of the first five days of an inpatient mental health care admission.
You have been asked to pay a $1,500 copayment for the inpatient mental health care. The inpatient admission was 10 days long, but you have been asked to only pay the $300 copayment for the first five days ($300 x 5 days = $1,500). 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 mental health services provided from November 3, 2020, to November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 12, 2020.
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 place of service on the CMS-1500form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for laboratory services provided to the enrollee on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole Sodium packets.
You asked the Plan to pre-approve the Pantoprazole Sodium packets. You say that it is medically necessary that the enrollee use Pantoprazole to achieve suppression of gastric irritation. The Plan denied your request. The Plan says Pantoprazole Packets and does not meet the Medicare criteria to be covered under the enrollee's Medicare Part B benefit.
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 Pantoprazole Sodium packets.
Benefits for the Pantoprazole Sodium packets 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee
from October 15, 2020, to October 18, 2020.
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 records do not include the time spent providing the services.
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 99291 is "evaluation and management of the critically ill
or critically injured patient, first 30-74 minutes."
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include
any documentation of the time spent rendering the services. This is required, as CPT 99291 is a time-based
code, and there needs to be documentation specifically that the services took between 30 and 74 minutes. 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 pay for critical care services (CPT 99291) provided to the enrollee
from October 15, 2020, to October 18, 2020.