Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee was medically stable with no evidence of need for supervision by PMR physician or needs acute rehab nursing care. Functionally given needing minimum assist to CGA, does not need IRF level of therapies with easy fatigability, does not need and will not tolerate IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status. 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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you just had hip surgery and need therapy. The
Plan denied your request. The Plan says your needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that you are hemodynamically stable. You are at standby assist for mobility. You have no complex
wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and
warranting a SNF. Therefore, a SNF admission is at this time not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99202), electric stimulation therapy (97014), x-ray exam of the cervical spine (72040), chiropractic manipulative treatment (98940) and the low level laser treatment (S8948) rendered by the out of network (OON) provider from January 2, 2020 to January 16, 2020.
You asked the Plan to issue reimbursement 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 rendered 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 issue reimbursement for the office visit (99202), electric stimulation therapy (97014), x-ray exam of the cervical spine (72040), chiropractic manipulative treatment (98940) and the low level laser treatment (S8948) rendered by the out of network (OON) provider from January 2, 2020 to January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided November 26, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. 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, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venlafaxine for the enrollee.You asked the Plan to pre-approve Venlafaxine under Medicare Part B. You say that this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered under Medicare 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-approve Venlafaxine for the enrollee.Benefits for Venlafaxine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided from January 22, 2020 through February 4, 2020.
You asked the Plan to pay for the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not a covered benefit under 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided from January 22, 2020 through February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe respiratory virus infectious agent detection rendered on January 2, 2020.You asked the Plan to pay forthese 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. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of atelectasis. A swab was obtained from the nasopharynx. The results of the respiratory virus detection panel are in the case file. There are no additional clinical records on which to base medical necessity in this case. The documentation in the case file does not support that the respiratory virus infectious agent detection testing was medically reasonable and necessary for the enrollee in this case.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 forthe respiratory virus infectious agent detection rendered on January 2, 2020. Local Coverage Article (LCA) A57579 referenced by the Plan is not binding for the state in which the testing was performed and was not used in the MAXIMUS determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on November 4, 2019.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services (99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 days of continued inpatient behavioral health treatment. You asked the Plan to pre-approve 4 days of continued inpatient behavioral health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 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 pre-approve 4 days of continued inpatient behavioral health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 7, 2020 forward as this patient 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 while not showing any threats to the safety of herself or others. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 days of continued inpatient behavioral health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 days of continued inpatient behavioral health treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora SNF stay provided from December 1, 2019 to December 27, 2019.You asked the Plan to waive the copayment fora SNF stay. You say that you were told that the insurance would not cover your stay.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 $0 copayment per day for days 1-20, and a $172 copayment per day for days 21-100 for SNF care. You had a SNF stay from December 1, 2019 to December 27, 2019. The record shows that you had previous SNF stays for a total of 21 days. Therefore, you are responsible to pay $3,513.21, which is less than the total copayment amount. You have been asked to pay $3,513.21 for a SNF stay. A SNF stay falls within the SNF 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 fora SNF stay provided from December 1, 2019 to December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the pneumatic compression device and appliances provided on February 5, 2020.
You asked the Plan to pay for the pneumatic compression device and appliances. You say that the Plan should pay this claim. The Plan denied your request. The Plan says that payment for durable medical equipment is limited to the lower of the actual charge for the equipment or the fee established.
The Plan must follow Medicare rules. Medicare rules say that Section1834 of the Act requires the use of fee schedules under Medicare Part B for reimbursement of durable medical equipment (DME) and for prosthetic and orthotic devices, beginning January 1 1989. We find that there is no evidence that the fee schedule amount was paid. Therefore, we decided that the Plan has to pay the fee schedule amount for the pneumatic compression device and appliances provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the chemotherapy administration. We decided that the Plan does not have to waive the coinsurance for the nivolumab injection.
You asked the Plan to waive the coinsurance for the nivolumab injection and chemotherapy administration. You say that you are wondering why you are being charged. You say that you don't want to pay it. The Plan says that the coinsurance applied correctly. We decided that the Plan has to waive the coinsurance for the chemotherapy administration.
The chemotherapy administration is considered a provider and professional service. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for provider and professional services at an in-network outpatient hospital. The Plan contract does not clearly say how much enrollees must pay for provider and professional services at an in-network outpatient hospital. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the chemotherapy administration.
We also decided that the Plan does not have to waive the coinsurance for the nivolumab injection.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs at an in-network outpatient hospital. Therefore, we decided that the Plan does not have to waive the coinsurance for the nivolumab injection.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 pre-approve inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 4, 2020 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats to the safety of yourself or others.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 treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CTA of the chest and abdomen.
You asked the Plan to pre-approve the CTAs. The Plan denied your request. The Plan says the services are not medically necessary.
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 pre-approve the CTAs. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 85-year-old male with known multi-vascular disease, but no clear change in symptoms, only mildly reduced left ABI, only mild claudication and no changes reported on most recent ultrasound and CT scanning. In addition, there is no documented thoracic aortic abnormality. In this circumstance of no documented thoracic aortic abnormality and no reported clinical change or imaging change the documentation does not support the medical necessity for thoracic CT scan or repeat abdominal CT scan. 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 CTAs have not been met. Therefore, we decided that the Plan does not have to pre-approve a CTA of the chest and abdomen.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 21, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because this was a screening. 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 $225 copayment for outpatient surgery. The medical records show that you had polyps removed during a colonoscopy on January 21, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $225 copayment. You have been asked to pay a $225 copayment for a colonoscopy. A colonoscopy falls 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 a colonoscopy provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the DME purchased January 20, 2020 through January 24, 2020 from a non-Medicare provider.You asked the Plan to reimburse for the DME. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says these services are not covered by Medicare and the provider is not certified for Medicare.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 reimburse for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.Review of the file shows that you purchased DME from January 20, 2020 through January 24, 2020 from a non-Medicare provider. Your EOC states, while you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare.Therefore, we decided that the Plan does not have to reimburse for the DME purchased January 20, 2020 through January 24, 2020 from a non-Medicare provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gym membership purchased from January 1, 2019 through December 31, 2019.You asked the Plan to pay forthe gym membership. You say that the claim was processed incorrectly.The Plan denied your request. The Plan says you exhausted your benefit allowance.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. You exhausted your benefit allowance, because the plan paid the $150 allowance.Therefore, we decided that the Plan does not have to pay forthe gym membership purchased from January 1, 2019 through December 31, 2019.