Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the services are necessary. The Plan denied your request. The Plan says you have reached 100 days in a SNF.
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 you received 100 days of SNF care during the benefit period from October 2, 2020 to April 14, 2021. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist brace and related accessory provided on September 17, 2020.
You asked the Plan to pay for the brace and accessory. You say that this was medically necessary and should be covered. The Plan denied your request. The Plan says there is no evidence of full exam to support the need for this brace.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the brace and accessory. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee with a credible physical examination of the wrist. 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 brace and accessory have not been met. Therefore, we decided that the Plan does not have to pay for the wrist brace and related accessory provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance.

You asked the Plan to pay for the periodontal maintenance. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.

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 periodontal maintenance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit.

You asked the Plan to waive the copayment for the dermatology visit. You say that you don't remember seeing the doctor on that date, but you did have light therapy. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for specialist visits.

The medical records clearly show that you were seen by the dermatologist for complaints of a rash. The records show that you were diagnosed with pruritus during that visit and also received phototherapy. You have been asked to pay a $40 copayment for the dermatology visit. The dermatology visit falls within the specialist visits 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 dermatology visit.
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 14, 2020 to November 12, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for bacteremia and heart failure. The physical therapy note dated September 25, 2020 states she needed contact guard assist to sit up and lie down, stand up, and walk 15 feet. She had no skilled nursing needs. She did not require skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level 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 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 14, 2020 to November 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the cataract surgery services provided from May 25, 2020 to June 1, 2020 while outside of the United States.
You asked the Plan to pay for the cataract surgery services while outside of the United States. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. We looked at the file, the Plan's contract and Medicare rules. The Plan contract says you are covered for emergency care and urgently needed care world-wide. We received your written letter that says you believed you were experiencing an unusual condition with your vision and were worried about doing further damage to your eyes if left untreated for the unknown time you would be outside of the U.S. due to COVID-19. Medicare says that an emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan.
Based on this information, we decided that Medicare rules for coverage of the cataract surgery services while outside of the United States have been met. Therefore, we decided that the Plan has to pay for the cataract surgery services provided from May 25, 2020 to June 1, 2020 while outside of the United States.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis coded as L3960 provided on August 28, 2020.
You asked the Plan to pay for the orthosis. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that durable medical equipment is covered only when there are both a physician order, proof of delivery and the records show the order was placed appropriately. We looked at the file and Medicare rules. In this case, it cannot be confirmed the enrollee had a prior telehealth visit with the ordering physician which would facilitate or support the orthosis billed. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for the orthosis coded as L3960 provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services with code A0431.

You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this was billed with an inappropriate or invalid modifier.

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 is Ambulance service, conventional air services, transport, one way (rotary wing).

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 ambulance services. Our reviewer says that the medical records do not support the services billed. Our physician reviewer found the enrollee received services for Healthcare Common Procedure Coding System (HCPCS) A0431: Ambulance service, conventional air services, transport, one way (rotary wing) with modifier QL (Patient pronounced dead after ambulance called). Documentation submitted was reviewed and does not meet criteria. Ambulance report documents the enrollee expired after takeoff and was not transported. Per Medicare Processing Manual Chapter 15 - Modifier QL should be reported with mileage HCPCS code. Therefore, this modifier reported with HCPCS A0431 is inappropriate.

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services with code A0431.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by a non-participating provider on January 6, 2021.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services are not covered when provided by a non-participating provider.
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 when provided by a non-participating provider. Therefore, we decided that the Plan does not have to pay for the dental services provided by a non-participating provider on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital services were medically necessary. The Plan denied your request. The Plan says the inpatient hospital services were 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 review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided from August 7, 2020, through October 17, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Medicare does not pay for the services of a naturopath. The Plan contract says that naturopath services are not covered under any condition. Therefore, we decided that the Plan does not have to pay for an office visit provided from August 7, 2020, through
October 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the liver biopsy procedure you had at an outpatient hospital facility.

You asked the Plan to reduce the copayment for the liver biopsy procedure. You say that you should only be charged the $175 copayment for diagnostic procedures and tests. The Plan denied your request. The Plan says you were charged this copayment 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 $325 copayment for surgery services in an outpatient hospital facility.

You have been asked to pay a $325 copayment for the liver biopsy procedure. The biopsy you received is considered a surgical service. The definition of the procedure code your doctor billed for this service (47000) is categorized in the Current Procedural Terminology (CPT) manual as included in the 'Surgical Procedures on the Liver' classification grouping. That is why the liver biopsy procedure falls within the surgery services in an outpatient hospital facility 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 the liver biopsy procedure you had at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiology visit.

You asked the Plan to waive the copayment for the cardiology visit. You say that you did not go into the office on that date. The Plan denied your request. The Plan says this copayment was charged 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 $20 copayment for specialist visits.

The medical records from that date of service show that you were physically present in the office. Specifically, the records show that you were seen by the doctor as a follow-up on your hypertension and heart failure conditions. In addition, the records show that you had blood drawn during the visit and the blood was sent to the lab that same date. You have been asked to pay a $20 copayment for the cardiology visit. The cardiology visit falls within the specialist visits 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 cardiology visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on December 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 nursing facility care provided on December 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the hospital-to-hospital transfer via ambulance and inpatient services provided from September 16, 2020 to September 22, 2020.
You asked the Plan to pay for the hospital-to-hospital transfer via ambulance and inpatient services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the hospital-to-hospital transfer via ambulance and inpatient services by a contract provider. The file does not show that the Plan provided notice that the hospital-to-hospital transfer via ambulance and inpatient services would not be covered. Under Medicare rules, this means the hospital-to-hospital transfer via ambulance and inpatient services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the hospital-to-hospital transfer via ambulance and inpatient services provided from September 16, 2020 to September 22, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electric Nerve Stimulation (TENS) units and garments and supplies provided November 9, 2020.
You asked the Plan to pay for TENS units and garments and supplies. You say that this device was medically necessary for the enrollee. The Plan denied your request. The Plan says the device is not covered for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain when the criteria as listed in the Medicare rules section have been met. 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 TENS units and garments and supplies. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the patient is a 71-year-old female with chronic back/neck pain/radiculopathy. The patient does not have a diagnosis that would qualify for coverage of the TENS unit as necessitated by Medicare criteria. The requested device is not being used as part of a clinical study or postoperatively. The documentation does not reveal objective therapy notes revealing failure of therapy of the back or shoulder or a detailed objective neuromuscular exam indicating the patient has a diagnosis required by the local coverage determination. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TENS units and garments and supplies have not been met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electric Nerve Stimulation (TENS) units and garments and supplies provided November 9, 2020.