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

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the sooner the enrollee starts therapy, the better. You say that IRF care is needed so the enrollee has a better quality of life. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a history of stroke in January of 2021 and is living at home with persistent weakness despite home health physical therapy services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 26, 2021 by an out-of-network provider. You asked the Plan to pay for the laboratory services (87491, 87591, 87661). You say that the services were medically necessary in providing a medical diagnosis for the enrollee's referring physician. The Plan denied your request. The Plan says you did not request prior authorization as required. 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 had network providers available who could have provided 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 laboratory services provided on February 26, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on April 16, 2021.

You asked the Plan to pay for the dental services. You say that your Annual Notice of Changes (ANOC) for 2021 says that you pay 0% for panoramic film or diagnostic x-rays - 1 every 3 years. You say that your coverage includes 0-50% coinsurance for basic services. You say that you should only be responsible for $222.50, not the $445 that you were billed. You also say that you are on a very fixed income. You also say that The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says that panoramic x-ray is not listed as a covered service either. The Plan says that there were no changes to your mandatory dental coverage, therefore the ANOC does not apply. The Plan also says that the dental coverage you were looking at on page 14 was for a supplemental plan that would have to be purchased for them to apply.

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 x-rays you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services received on January 15, 2021.
You asked the Plan to waive the copayment for the services. You say that you believe this is to be paid by the plan. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulance services. You have been asked to pay a $200 copayment for the services. The services fall within the ambulance 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 ambulance services received on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 6, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 12 - indicating a home setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on February 16, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you are being charged this copayment on top of your primary care visit copayment even though they were just a day apart. You state that this copayment should be waived since you and your doctor didn't know the policy. 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 $10 copayment for laboratory services. You have been asked to pay a $10 copayment for the lab services. 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 lab services you received on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980) provided on April 29, 2021.
You asked the Plan to pay for the dental service. You say that you do not understand why this service is not covered. You also say that this service was necessary to prolong the life of your crown. The Plan denied your request. The Plan says crown repair necessitated by restorative material failure is not listed as a covered service.
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 crown repair necessitated by restorative material failure (D2980) provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cataract surgery services you received from March 30, 2021, to April 2, 2021, at an outpatient hospital facility.
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were told that your copayment would be $275, not $350. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the facility where you had this service is an outpatient hospital facility, not an ambulatory surgery center. That is why the $350 copayment applies.
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 $350 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $350 copayment for the cataract surgery. The cataract surgery falls within the outpatient surgery at 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 cataract surgery services you received from March 30, 2021, to April 2, 2021, at an outpatient hospital facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient hospital care provided from
July 8, 2021, through July 11, 2021.

You asked the Plan to provide coverage for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the inpatient admission was 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 provide coverage 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 that you were admitted for new onset diabetes with diabetic ketoacidosis. The medical record does not document that the treating physician had a reasonable expectation of a length of stay spanning two (2) or more midnights. The first note on July 9, 2021 indicated significant improvement. You could have been admitted for observation. The medical record at the time of admission does not document the anticipated two-night stay. The elements of the coverage rule are not satisfied. The requested service is not recommended. 

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 provide coverage for acute inpatient hospital care provided from July 8, 2021, through July 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ondansetron provided on May 5, 2021.

You asked the Plan to pay for the Ondansetron. You say that you were taken to the emergency room by ambulance and were given the medication at the hospital. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs.

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 Ondansetron provided on May 5, 2021.

Benefits for the Ondansetron 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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes one comprehensive exam and one panoramic x-ray every three plan years. You can find this information on pages 4-57 to 4-62 of the Plan's 2021 Evidence of Coverage (EOC). We looked at the file and Medicare rules. The Plan provided documentation showing that coverage was previously provided for a comprehensive exam and panoramic x-ray on October 15, 2020. Based on this information, we determined that the Plan's frequency limit for the panoramic x-ray and comprehensive oral exam have been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and comprehensive oral evaluation - new or established patient (D0150) provided April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided by the hospital on April 20, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were given a pill by the doctor's order and sent home with a prescription. You say that drugs had nothing to do with this claim. The Plan denied your request. The Plan says Medicare Part B does not cover drugs that are self-administered.
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 self-administered drugs provided by the hospital on April 20, 2021.
Benefits for the self-administered drugs 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 the Plan does not have to reimburse you $300 for a 2020 gym membership.
You asked the Plan to reimburse you for this membership. You say that you use the pool often and you feel the Plan should reimburse you for this gym membership. The Plan denied your request. The Plan says you provided a receipt that shows a payment of only $80. Therefore, $80 is approved towards the 2020 Wellness Benefit. The Plan attached documentation to show this reimbursement was processed.
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. The Plan can only reimburse you when valid receipts are submitted. The Plan only received a receipt for $80 reimbursed you the $80. The Plan's rules for any further reimbursement for gym benefits have not been met. Therefore, we decided that the Plan does not have to reimburse you $300 for a 2020 gym membership
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on February 16, 2021.
You asked the Plan to pay for the services provided. You say that the records support medical necessity. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. Train of Four Testing does not fit the criteria set by CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four Monitoring, therefore, it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four Monitoring.
The CPT Code Manual Definition of code 95955 electroencephalogram (EEG) during non-intracranial surgery The CPT Code Manual Definition of code 95908 nerve conduction studies; 3-4 studies. The CPT Code Manual Definition of code 95927 short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. We find that the CPT codes are not supported in the medical record. The records do not indicate that the most comprehensive code was billed for the services provided. 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 pay for the intraoperative neuromonitoring services provided on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray of the hip provided on February 24, 2021, at an outpatient hospital facility.

You asked the Plan to reduce the copayment for the x-ray. You say that this service was performed at a stand-alone facility, not an outpatient hospital, so the copayment should be less. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that because the allowable amount for this service ($79.31) is less than the copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $95 copayment for basic radiology services at an outpatient hospital facility. 

The enrollee has been asked to pay a $95 copayment for the x-ray. We confirmed that the facility where these services were rendered is considered part of an outpatient hospital facility. They bill as part of a hospital system, not as a standalone facility. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the x-ray of the hip provided on February 24, 2021, at an outpatient hospital facility.