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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 15, 2020.You asked the Plan to pre-approve these services. You say that you need more therapy.The Plan denied your request. The Plan says the continued services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on May 6, 2020 after hospitalization for heart failure and shortness of breath. Your conditions have been stable and you have not made significant progress with therapy. You have skilled nursing and skilled therapy needs but do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 15, 2020.
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 enrollee requires the services. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria that requires a high level of physician supervision in combination with therapy services in an inpatient 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 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote cardiovascular monitoring provided on November 18, 2019.
You asked the Plan to waive the copayment for the remote cardiovascular monitoring. You say that you have sleep apnea. You say that you were only monitored for one night. The Plan denied your request. The Plan says the copayment 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 $20 copayment for in-network diagnostic procedures and tests. You have been asked to pay a $20 copayment for the remote cardiovascular monitoring. The remote cardiovascular monitoring falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 remote cardiovascular monitoring provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.
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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical extraction (D7210) and resin composite (D2391) provided March 12, 2020.
You asked the Plan to pay for dental services. You say that your medical premium is automatically withdrawn and thought the dental was being withdrawn the same. The Plan denied your request. The Plan says this 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 surgical extraction (D7210) and resin composite (D2391) provided March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on June 3, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was not submitted with a modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 01214 is anesthesia for open procedures involving hip joint; total hip arthroplasty. We find that CPT code 01214 is not supported in the medical record. Specifically, the claim was not submitted with a required anesthesia services modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on June 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from November 1, 2019 through November 30, 2019.You asked the Plan to waive the copayment for the SNF services. You say that  The Plan denied your request. The Plan says that you are responsible for the copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per day for days 1-20 of SNF care and a $60 copayment for days 21-44of SNF care. You have been asked to pay a $911.23for the SNF services. The SNF services falls within days 1-20 of SNF care and days 21-44of SNF care benefit category. Your SNF care began on October 14, 2019. This means that you owe a $20 copayment for November 1stand November 2ndand a $60 copay per day from November 3rdto November 26th. This means that you have been asked to pay less than 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 skilled nursing facility (SNF) services provided from November 1, 2019 through November 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe subsequent nursing facility care provided on November 26, 2019 by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that it is your understanding that when a provider is called to see a patient during their nursing home stay, that your services would be covered by Medicare. You also say that if any authorization was needed, the nursing home would be responsible for obtaining the authorization.The Plan denied your request. The Plan says the treating provider is OON with the enrollee's health plan. The Plan also says that the Plan did not authorize the evaluation services that were provided to the enrollee.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care provided on November 26, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vedolizumab injection provided on December 2, 2019 and December 16, 2019.You asked the Plan to waive the coinsurance for the vedolizumab injections. You say that you weren't informed of the coinsurance. You say that you cannot afford this amount.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.You have been asked to pay a total of $2,165, which is less than the standard 20% coinsurance for the vedolizumab injections. The vedolizumab 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 vedolizumab injection provided on December 2, 2019 and December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80061, 84439 and 84443 provided on December 12, 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 documentation does not support whether the services were medically necessary.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. Review of the file shows that no medical records were provided to support that the services were medically necessary. With the information provided to the plan, determination of how the enrollee came to the servicing provider. 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 80061, 84439 and 84443 provided on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis LT, RT (L1851x2) and suspension sleeve LT, RT (L2397x2).
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis LT, RT (L1851x2) and suspension sleeve LT, RT (L2397x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on August 3, 2019. You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 an outpatient visit provided on August 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 for lab services provided on January 29, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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 Eliquis.Benefits for Eliquis 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 12, 2020.You asked the Plan to waive the copayment for the ER visit. You say that the ER was freezing and you hadn't eaten. You say that you shouldn't have to pay.The Plan denied your request. The Plan says the copayment 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 $50 for each Medicare-covered emergency room visit.You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups, including any pins when required (code D2950) for tooth #'s 8 and 10.
You asked the Plan to pre-approve the core buildups. You say that these procedures are necessary. You also say that you have been struggling with these teeth for months and you are almost certain that there is some infection and is harming your health. The Plan denied your request. The Plan says this 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 pre-approve core buildups, including any pins when required (code D2950) for tooth #'s 8 and 10.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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. 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 a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833 and L29397) provided on November 22, 2019.

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.

The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain 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 or replacement (if applicable).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthoses have not been met. Specifically, the record indicates the the Plan requested documentation of the duration of the member's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously purchased DME items related to the billed items. There is insufficient information to verify the supplies billed. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833 and L29397) provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says that the documentation received fails to indicate that the member is using insulin 3 or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on January 14, 2020.You asked the Plan to pay for the testing services. You say that the codes are supported by the physician's custom profile.The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.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 80307 and G0482 are not supported in the medical record. Specifically, the records provide do not show the tests were ordered based on clinical history or risk assessment. 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 presumptive and definitive drug testing provided on January 14, 2020