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 these services are medically necessary. The Plan denied your request. The Plan says that the care can be provided in current status and transfer to LTACH is not currently indicated.

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. You were admitted with cardiogenic shock following a STEMI and required mechanical support. You are currently unstable with new onset ischemic colitis and downward trending hemoglobin. You are receiving acute care services and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving that could be provided at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).

You asked the Plan to pre-approve a powered pressure-reducing air mattress (E0277). You say that the requested powered pressure-reducing air mattress (E0277) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested powered pressure-reducing air mattress (E0277).

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a powered pressure-reducing air mattress (E0277). Our reviewer says that the enrollee does not meet criteria for the requested powered pressure-reducing air mattress (E0277). Our physician reviewer found in this case, the beneficiary has limited mobility due to weakness and obesity. The documentation doesn't support that she has multiple stage 2 pressure ulcers located on the trunk or pelvis and has failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment program or a myocutaneous flap or skin graft. The requested pressure reducing support surface is 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 a powered pressure-reducing air mattress (E0277) have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on January 27, 2021.

You asked the Plan to waive the coinsurance for DME. You say that the device does not work. 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 20%
coinsurance for DME and related supplies.

You received DME on January 27, 2021. The total allowed amount is $261.68 and 20% of that is $52.34.

You have been asked to pay the total coinsurance amount of $52.34 for DME. DME falls within the DME and
related 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 coinsurance for DME provided on January
27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on January 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
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 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 services provided to the enrollee by an out-of-network
provider on January 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
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 you are currently undergoing treatment at an acute care hospital (ACH) for shock and coagulopathy. You were temporarily intubated/ventilated, but have since been extubated, and no longer on a ventilator. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring to the LTACH. You can remain at the current ACH until such time that no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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 admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and management of a new patient (99203) provided on September 22, 2020, by an out of network (OON) provider.

You asked the Plan to pay for office or other outpatient visit for the evaluation and management of a new patient. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 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 office or other outpatient visit for the evaluation and management of a new patient (99203) provided on September 22, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 7,
2021.

You asked the Plan to pay for periodontal maintenance. You say that the service should be covered. The Plan
denied your request. The Plan says the service at issue 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
periodontal maintenance (D4910) provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the vitrectomy chair purchased on February 15, 2021.

You asked the Plan to reimburse you for the vitrectomy chair. You say that the chair was medically necessary after surgery. The Plan denied your request. The Plan says that vitrectomy chairs are not covered under Medicare or the Plan.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the vitrectomy chair by a contract provider. The file does not show that the Plan provided notice that the vitrectomy chair would not be covered. Under Medicare rules, this means the vitrectomy chair is considered approved by the Plan. Therefore, we decided that the Plan has to reimburse you for the vitrectomy chair purchased on February 15, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient hospital clinic services (CPT code G0463) provided on January 26, 2021.

You asked the Plan to waive the deductible for outpatient hospital clinic services. You say that you only have a $400 deductible combined in and out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you received outpatient hospital clinic services on January 26, 2021. At the time of services rendered you had not met your $400 deductible; therefore, you have been asked to pay $112.95 for the services to apply to your deductible. 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 deductible for outpatient hospital clinic services (CPT code G0463) provided on January 26, 2021.
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 August 9, 2020, to August 16, 2020.
You asked the Plan to waive the copayment for SNF services. You say that you were not aware of a copayment. The Plan denied your request. The Plan says the claim has processed correctly in this case.
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 $100 copayment each day for days 21 to 30 for SNF care. You have been asked to pay a $300 copayment for the 23 days total you spent in SNF care. This service falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided August 9, 2020, to August 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser coagulation of prostate services coded 52647 provided on April 23, 2019.

You asked the Plan to pay for the laser coagulation of prostate 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.

In this case, the CPT Code Manual definition of code 52647 is laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed).

We find that CPT code 52647 is not supported in the medical record. Specifically, the operative report did not include documentation of a complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) laser coagulation of prostate, including control of postoperative bleeding; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laser coagulation of prostate services have not been met. Therefore, we decided that the Plan does not have to pay for the laser coagulation of prostate services coded 52647 provided on April 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary resin partial denture base repair (D5612)
provided on January 15, 2021.

You asked the Plan to pay for the maxillary resin partial denture base repair. You say that you were not aware
that this service would not be covered. The Plan denied your request. The Plan says this service is not covered.

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
maxillary resin partial denture base repair (D5612) provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) evaluation (D0140) and intraoral x-ray (D0220) provided on January 28, 2021.

You asked the Plan to pay for the limited exam and x-ray. You say that you cannot afford this surprise expenditure, and these services were necessary for your teeth and health. The Plan denied your request. The Plan says these services are not covered by the supplemental dental 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 (problem-focused) evaluation (D0140) and intraoral x-ray (D0220) provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
October 8, 2020.

You asked the Plan to pay for the office visit. You say that you requested enrollment with the Plan but did not
receive any response. You say that you are losing out on reimbursement and the claim should be processed at
the contracted rate. The Plan denied your request. The Plan says prior authorization was required but not
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 had network providers
available who could have provided 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 the office visit provided by an out-of-network
provider on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 13, 2020.

You asked the Plan to pay for drug testing. You say that you are requesting that the Plan not penalize your lab for being out-of-network. 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.

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on November 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 10, 2021.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 10, 2021. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on October 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like this claim reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON provider.

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 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 the psychiatric diagnostic evaluation (90792) provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the Part B drugs you received on December 2, 2020.

You asked the Plan to adjust the cost share. The Plan denied your request. The Plan says you are responsible for the coinsurance.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 17% coinsurance for Medicare Part B prescription drugs.

Review of the file shows that you were provided Part B drugs on December 2, 2020. You have been asked to pay a 17% coinsurance for the drugs. The drugs 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 adjust the cost share for the Part B drugs you received on December 2, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lesion removal provided on January 8, 2021.

You asked the Plan to waive the copayment for the lesion removal. You say that you received two bills but do not understand why you are being charged $65. You say that you should have been told there would be an extra charge. 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 $260 copayment for each Medicare-covered outpatient hospital service.

You have been asked to pay $105, which is less than the standard $260 copayment for the lesion removal. The lesion removal falls within the "Outpatient hospital services" benefit category. The records show the lesion removal was billed by the hospital. 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 lesion removal provided on January 8, 2021.