Persius/hicric huggingface dataset:
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 enrollee will require inpatient care on a prolonged basis.The Plan denied your request. The Plan says the enrollee can stay in the current facility for as long as it takes.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care and oxygen supplementation, intravenous antibiotics, neurologic monitoring, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 12, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approvea semi-electric hospital bed. You say that the enrollee would greatly benefit from the use of a semi-electric hospital bed.The Plan denied your request. The Plan says the documentation submitted does not support the need for frequent changes in body position orimmediate need for a change in body position.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We asked our physicianreviewer 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 a semi-electric hospital bed. Our reviewer says that  Our physician reviewer found We looked at the file and Medicare rules. The record does not support the criteria. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.You asked the Plan to pre-approve the requested testing. You say that you have skin cancer.The Plan denied your request. The Plan says there is not an additional benefit that covers screening genetic studies beyond what Medicare covers.The Plan must follow Medicare rules. Medicare rules say that genetic testing is only covered under certain medical indications.We looked at the file and Medicare rules. The records do not show that you have a personal history of breast, ovarian, fallopian tube, primary peritoneal,pancreatic, or prostate cancer. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that in 2018 you were fitted for teeth. You also say that this office is now closing. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete dentures are covered once every five plan years. The record shows that you received a complete maxillary denture and a complete mandibular denture on April 4, 2018 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82947 and 80061 provided on December 17, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 82947 and 80061 are not supported in the medical record. Specifically, the documentation did not include a valid physician order/lab requisition form or medical records signed by the ordering physician for the billed tests. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82947 and 80061 provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and sleeves (E0667) for the enrollee.
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that this equipment is medically necessary. The Plan denied your request. The Plan says that there is inadequate documentation of a four week trial with basic pneumatic compression device with associated garment.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and sleeves (E0667) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a blood pressure apparatus with cuff and stethoscope.You asked the Plan to providea home blood pressure monitor (A4660). You say that you were advised by your cardiologist and kidney doctor that you need a standard blood pressure cuff.The Plan denied your request. The Plan says home blood pressure monitors are onlycovered for home dialysis patientsor white coat hypertension.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to provide a blood pressure apparatus with cuff and stethoscope.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided from October 29, 2019 to December 20, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is not supported in the medical record. Specifically, the documentation does not include a valid physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided from October 29, 2019 to December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ondansetron tablet provided on January 7, 2020. You asked the Plan to pay for the Ondansetron. You say that you should not have to pay for the pain medication because the doctor made the choice for you. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs. The Plan also says that if you receive self-administered drugs that are not covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill you for the drug. 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 pay for the Ondansetron tablet provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hospital services provided on December 2, 2019 through December 12, 2019.You asked the Plan to reimburse you for the hospital services. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says no medical records or itemized statements were submitted support these charges.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Specifically, the record does not include medical records for services rendered on December 2, 2019 through December 12, 2019. There is insufficient information to determine whether payment is due and the amount of payment.Therefore, we decided that the Plan does not have to reimburse you for hospital services provided on December 2, 2019 through December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve specialist services. You say that you would prefer to see a female doctor.The Plan denied your request. The Plan says there are in-network female providers available for these services.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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on February 18, 2020. You asked the Plan to waive the copayment for podiatry services. You say that you should only owe a $30 copayment for specialist services. 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 $50 copayment for podiatry services. You have been asked to pay a $50 copayment for podiatry services. Podiatry services fall within the podiatry
services 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 podiatry services provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the post-cataract laser surgery provided on February 4, 2020.
You asked the Plan to waive the copayment for the post-cataract laser eye surgery. You say that you are being charged too much for a five-minute procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulatory surgical center and outpatient hospital visits. You have been asked to pay a $200 copayment for the post-cataract laser eye surgery. The post-cataract laser eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 post-cataract laser surgery provided on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve requested physician consultation.
You asked the Plan to pre-approve the physician consultation. The Plan denied your request. The Plan says the services are available within the network of providers.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician consultation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance, periodic oral evaluation, and sales tax provided on January 20, 2020 by an OON provider.You asked the Plan to pay for the periodontal maintenance, periodic oral evaluation, and sales tax. You say that you are at a higher risk for having gingivitis and periodontitis. You also say that the Plan should cover your exam since you are maintaining your health.The Plan denied your request. The Plan says periodontal maintenance is not a covered benefit. The Plan also says that these services were rendered by an OON provider and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.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, periodontal maintenance is not among those covered under this benefit. The contract clearly states that you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance, periodic oral evaluation, and sales tax provided on January 20, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar orthosis.
You asked the Plan to pre-approve a lumbar orthosis. You say that the orthosis is medically necessary. The
Plan denied your request. The Plan says the orthosis is not supported in the records received.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Medical records supporting medical necessity for the orthosis were
requested by the Plan but not received. Based on this information, we decided that Medicare rules for coverage
of a lumbar orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a
lumbar orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage ofan IRF admission.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 the enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee does not need an acute inpatient rehabilitation admission as she cannot retain any of the functional skills taught in an IRF due to dementia. The enrollee may benefit from further physical 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 and 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-approvean 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 an orthopedic mattress.You asked the Plan to pre-approve an orthopedic mattress. You say that you need an orthopedic bed mattress.The Plan denied your request. The Plan says you do not have a hospital bed therefore a mattress is not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Mattresses are only covered for hospital beds. Based on this information, we decided that Medicare rules for coverage of an orthopedic mattress have not been met.Therefore, we decided that the Plan does not have to pre-approve an orthopedic mattress.