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

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from July 27, 2019 through July 29, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient mental health care. Our physician reviewer found based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to themselves or others but was without agitation or aggression without perceptual disturbance including auditory, visual hallucinations or acute threats the safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from July 27, 2019 through July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that under Medicare, the request 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 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 you were medically stable with no evidence of need for supervision by PMR physician or that you need acute rehab nursing care. Functionally, you need physical therapy (PT) and occupational therapy (OT) but you do not require IRF level of therapies. You may benefit from further PT and an OT but you do not require an intensive therapy program. Your rehab needs can be met at a lower intensity setting such as in an SNF or in-home with services. IRF admission is not medically necessary based on your medical stability. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone 3mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that the authorization should be reconsidered and approved. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Eszopiclone 3mg tablet for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvebilateral breast reduction (19318).You asked the Plan to pre-approvebilateral breast reduction. You say that you need this due to pain and medication allergies.The Plan denied your request. The Plan says that you have not tried non-surgical treatment.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bilateral breast reduction. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you have expected symptomatology from your severely enlarged size, which has failed conservative medical management. There is no other conservative management that would likely resolve your condition. Breast reduction is the only reasonable correction that would likely give you resolve or significantly improve your functional impairment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral breast reduction have been met.Therefore, we decided that the Plan has to pre-approvebilateral breast reduction (19318).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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 6, 2020.
You asked the Plan to waive the copayment for emergency care. You say that your doctor referred you to the
emergency room so you should not be responsible for 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
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 emergency care provided on
April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for BiPAP from an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for BiPAP from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need rehab to return to your previous state in order to take care of your husband. The Plan denied your request. The Plan says you are not expected to be able to take part in 3 hours of therapy a day.
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 physician reviewer found that you had an intertrochanteric femur fracture after a fall and had a fracture repair. You were at minimal assist with transfers, contact guard assist with bed mobility, and minimal assist with ambulation using a rolling walker. You are 25% weight bearing. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You have had no significant postoperative complications. You may benefit from physical and occupational therapy, but the documentation does not support that your functional status requires an 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on January
29, 2020.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you were never informed of
the coinsurance when you enrolled. You say you should not be held responsible because you cannot afford it.
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 20% of
the cost for Medicare Part B drugs and chemotherapy drugs.
You have been asked to pay a total of $220.12 which 20% of the total allowed amounts for the Part B
injections. The total allowed amounts is $1,100.58. ($1,100.58 x 20% = $220.12). The Part B injections fall
within the "Medicare Part B prescription drugs" 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
coinsurance for the Part B injections provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 13, 2020.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the denial lacks the details of what happened during the appointment. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 limited oral evaluation (D0140) provided on March 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a need for skilled nursing care, such as complex wound management, or the administration of intravenous fluids or medications.
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 services are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. There is no evidence of a significant change in your chronic medical conditions. You have no evidence of a complex wound or new enteral feeding or other skilled nursing need. The requested services are 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefree nipple graft procedure.You asked the Plan to pre-approvefree nipple graft. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this service is correct.The Plan follows Medicare rules. Medicare rules say that reduction mammoplasty may be covered under certain clinical conditions. 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 free nipple graft. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested free nipple graft. Our physician reviewer found the enrollee directly satisfies the Medicare medical necessity criteria for a breast reduction, which has already been authorized by the Plan. The request for a separate nipple areolar reconstruction is not considered medically necessary as this should be an integral part to the bilateral breast reduction. A typical breast reduction includes breast volume reduction and nipple areolar elevation to a more anatomic position. Performing a free nipple graft would be part of nipple areolar elevation to a new position and should not be considered as a separate procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of free nipple graft have not been met. Therefore, we decided that the Plan does not have to pre-approvefree nipple graft procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approvecontinued inpatient psychiatric hospital care after July 30, 2020.You asked the Plan to pre-approvecontinued psychiatric inpatient care. You say that the member is a danger to himself.The Plan denied your request. The Plan says that that a reasonable and diligent effort was made by the staff to obtain the necessary medical records from your provider regarding your case and no records were received.The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the enrollee's inpatient care.In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs with this discharge.Therefore, we decided that the Plan has to pre-approvecontinued inpatient psychiatric hospital care after July 30, 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 usthe 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 drug testing services (HCPCS G0483) provided to the enrollee on August 26, 2019.
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 support the services billed.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence of provider concern for drug abuse/misuse.
A UDS was not performed or reviewed prior to performing the UDT. There is no evidence that the UDT was tailored to the enrollee's current addictions and/or medications. The laboratory requisition was neither signed nor dated by the provider. Therefore, the documentation does not support that the provided, broad-sweeping, confirmatory UDT was medically necessary, reasonable or properly ordered. 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 pay for drug testing services (HCPCS G0483) provided to the enrollee on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 17, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 29, 2020 by a non-network provider.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 rendered by a non-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 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 forthe medical services provided on January 29, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (T1020) provided from January 1, 2020, to January 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code T1020 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (T1020) provided from January 1, 2020, to January 31, 2020.