Persius/hicric huggingface dataset:
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 records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the submitted information does not show that the enrollee
can tolerate or actively participate in at least two therapy modalities at least three hours per day at least five
days per week. The Plan says that IRF care is medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require physical therapy and occupational therapy services but, based on the medical records provided,
does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this
case.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you fell in the bath and broke the skin on your nose. You say that you do not remember if you called for the ambulance or if the hotel staff did. You stated that the ambulance responders did not touch you or provide you with any medication. You saythat you are on a fixed income and cannot afford the cost of the bill. You asked the Plan to reconsider providing payment for the services.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 March 3, 2020. 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 forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray, alveoloplasty in conjunction with extractions, and comprehensive oral evaluation provided on March 24, 2020 and March 26, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray, alveoloplasty in conjunction with extractions, and comprehensive oral evaluation. You say that you asked the provider to check your benefits because all you wanted was an emergency tooth extraction. You also say that you were only made aware that you would have to pay $65 to have the infection taken care of.The Plan denied your request. The Plan says first intraoral periapical x-ray and alveoloplasty in conjunction with extractions are not covered benefits. The Plan also says that benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been exceeded.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, first intraoral periapical x-ray and alveoloplasty in conjunction with extractions are not among those covered under this benefit. The contract also clearly states that exams are limited to two procedures per calendar year. The record shows that you received a periodic oral evaluation on January 29, 2020 and March 19, 2020 and your exams benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray, alveoloplasty in conjunction with extractions, and comprehensive oral evaluation provided on March 24, 2020 and March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.
You asked the Plan to pay for a shower chair. You say that you are appealing the Plan's denial of reimbursement for your shower chair. You say that the shower chair is medically necessary for you. You stated that you cannot stand in the shower due to your medical issues and you needed the shower chair to sit in while you wash. You say that you received approval from your treating physician to order the shower chair and you asked the Plan to reimburse you for it. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
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 enrollee would benefit from inpatient rehab.The Plan denied your request. The Plan says the notes do not show that the enrollee specifically requires the involvement of a doctor in the field of rehabilitation medicine.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 with regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespine surgery.You asked the Plan to pre-approvespine surgery. 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. 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 spine surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found lumbar surgery with the use of a spinous process device is not medically needed. Those devices including Coflex remain experimental. More research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespine surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Diagnostic digital breast tomosynthesis (77062).
You asked the Plan to pay for the Diagnostic digital breast tomosynthesis. You say that the service was medically necessary The Plan denied your request. The Plan says the code billed is not covered by Medicare.
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 77062 is not supported in the medical record. Specifically, the code is not valid for Medicare purposes per the 2020 Year National Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of the Diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for Diagnostic digital breast tomosynthesis (77062).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided from December 11, 2019 to December 31, 2019.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is ineligible to bill Medicare.
The plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows the physician services were provided by a provider that has not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services provided from December 11, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental consultation (D9310) and cone beam CT scan
(D0380) provided April 15, 2020.
You asked the Plan to pay for the dental services. You say that your dentist had sent you to this specialist
because you ware having a lot of pain and nothing showed in the x-rays. This was the only way to find the
problem. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 dental
consultation (D9310) and cone beam CT scan (D0380) provided April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services (D1110, D0120, D0270) provided by an out-of-network dentist on February 3, 2020.You asked the Plan to pay forthe dental services. You say that the services were medically necessary.The Plan denied your request. The Plan says your dental benefit does not cover services received outside the plan's network.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. Services received out-of-network are not a covered benefit.Therefore, we decided that the Plan does not have to pay fordental services (D1110, D0120, D0270) provided by an out-of-network dentist on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for visual field examination (92083) provided
March 4, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you have been taking this test
for over 10 years and have never been billed a copayment. You do not feel a copayment for this test is fair. The
Plan denied your request. The Plan says the claim processed and the correct copayment was applied.
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 for
each Medicare covered exam for Vision care.
You have been asked to pay $20 for the vision services. The vision services falls within the Vision 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 visual field examination (92083) provided
March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided on January 6, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient mental health services. You say that the Plan us required to pay Federally Qualified Health Centers, at least the original Medicare rate to out-of-network providers.The Plan denied your request. The Plan says prior authorization was 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 hasto 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. Lock-in rules still apply for Federally Qualified Health Centers; therefore, since the provider is out-of-network the Plan has correctly denied paid. 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 foroutpatient mental health services provided on January 6, 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 the panoramic x-ray and adjunctive pre-diagnostic test provided on October 2, 2019.You asked the Plan to pay for the panoramic x-ray and adjunctive pre-diagnostic test. You say that the provider advertised that x-rays and a cleaning would cost $59.00. You also say that only the enrollee's bottom teeth had x-rays, and they did not do any cleaning.The Plan denied your request. The Plan says these services are not covered benefits.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 panoramic x-ray and adjunctive pre-diagnostic test provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on March 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. 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.
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 outpatient hospital services provided on March 5, 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 the two surface resin-based composite and three surface
resin-based composite provided on February 24, 2020.
You asked the Plan to pay for the resin-based composites.. You say that you were under the impression that
you would receive 50% coverage for two visits, not two teeth. You also say that you feel that the policy booklet
is not clear in meaning two teeth. The Plan denied your request. The Plan says the benefits for these services
have been satisfied and the frequency limitation has been exceeded.
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, restorations are limited to two
procedures per calendar year. The record shows that you received two fillings on February 13, 2020 and your
restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two
surface resin-based composite and three surface resin-based composite provided on February 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled therapy visits.
You asked the Plan to pre-approve the skilled therapy visits. You say that the services are medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the skilled therapy visits. Our reviewer
says that 4 additional skilled physical therapy visits are not medically necessary. Our physician reviewer found
8 therapy visits were already approved by the health plan. The documentation does not support that the unique
skills of a professional therapist are required at this time to provide an additional 4 therapy sessions.
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 skilled therapy visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional skilled therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient clinic visit. 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.
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 outpatient clinic visit provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 16, 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical examination and evaluation (92014) provided
November 20, 2019.
You asked the Plan to pay for the vision services. You say that the provider has balance billed you after she
told you that Medicare would cover all but one eye test. They had made you pay the same day. This was your
one year cataract surgery exam. The Plan denied your request. The Plan says the claim processed to apply the
deductible for diagnostic eye exam in accordance with the Evidence of Coverage. At the time of service, the
plan deductible of $250 was not met.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $250 deductible. After your yearly deductible is met, you pay $45 for
each Medicare covered exam to diagnose and treat diseases or conditions of the eye.
The item or service you asked the Plan to pay for falls within the benefit category Vision care. The Plan has
followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible. This cost sharing
is a contractual obligation that had not been met at the time the vision services was received on November 20,
2019. Therefore, we decided that the Plan does not have to pay for medical examination and evaluation (92014)
provided November 20, 2019.