Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital visit (99233) July 10, 2020.  You asked the Plan to pay for the hospital services. You say that please reprocess the claim for pamyent with the attached proof of timely filing. The Plan denied your request. The Plan says the time limit for filing has expired.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the hospital services was not filed until October 3, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for subsequent hospital visit (99233) July 10, 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. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor at least 3 times a week.  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 physician reviewer found that you are at a minimal assist level for sitting up, maximal assist for standing, standby assist for seating tooth brushing and face washing. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a gingival irrigation (D4921) provided by a participating provider on October 13, 2021.  

You asked the Plan to pay for a gingival irrigation. You say that this procedure was medically necessary. You say that you were in a lot of pain. The Plan denied your request. The Plan says the dental services that were provided 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 a gingival irrigation (D4921) provided by a participating provider on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair you purchased on July 27, 2020.

You asked the Plan to pay for the lift chair. You say that you are asking for reimbursement for this item because the provider said they didn't take insurance. The Plan denied your request. The Plan says you did not file a claim for payment within the 12-month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The Evidence of Coverage also says that enrollees have 12 months to file a claim for reimbursement for medical items or service. 

The record shows that a claim for the lift chair was not filed until September 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the lift chair you purchased on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection you received on
September 2, 2021.

You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you would like this drug
covered 100%. The Plan denied your request. The Plan says you were charged this coinsurance 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 drugs.

You have been asked to pay 20% coinsurance for the Synvisc injection. The Synvisc injection falls within the
Medicare Part B 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 Synvisc
injection you received on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2021.  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 the services were not billed correctly.  The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313).  

You asked the Plan to pre-approve an expandable controller. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this equipment is not medically reasonable and necessary.  

The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria listed 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically reasonable and necessary. Our physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The patient does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The patient does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient has 3 power options of tilt, recline, and power elevating leg rests but the patient does not need to control the power options through a joystick. The patient's upper extremity strength and function support that the patient can control any power options through their own switches.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 11, 2021, to August 15, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were previously in another hospital that released you too soon. You said that you should not have to pay this copayment because you had to return to the emergency room later the same day as your discharge. You think that because you already paid 5 days' worth of copayment to the first hospital that no additional copayment is due. 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 $395 copayment per day for days 1-5 for inpatient hospital care.  During this admission, you were in the hospital for 4 days.  You were charged a $395 copayment per day, for a total of $1580. According to your contract, you pay this copayment each time you are admitted to the hospital, regardless of the reason for the admission. 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 inpatient hospital services you received from August 11, 2021, to August 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications and you have stable vital signs. You are at a modified independent to contact guard assist level with transfers and gait to 50 feet with a rolling walker. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional PT visits.  You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 ten (10) additional PT visits.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been given additional therapy to be instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transit kit, non-standard seat width, and brake lock extension for a wheelchair.  You asked the Plan to pre-approve the services. You say that the chair cannot be any less wide in order to accommodate the body. The Plan denied your request. The Plan says Medicare does not cover options for use outside the home.  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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a transit kit is used outside of the home, and is used for travel. This exceeds your medical need and is not primarily medical in nature, and is not medically necessary. There are no seating measurements provided in the documentation to support a non-standard seat width, so the criteria for that is not met. A brake lock extension for a wheelchair exceeds your medical need as the requested wheelchair includes a standard wheelchair lock  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transit kit, non-standard seat width, and brake lock extension for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided October 19, 2021.

You asked the Plan to pay for the medical eye refraction. You say that you were not informed that this service would not be covered. The Plan denied your request. The Plan says medical eye refractions are not covered under your benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided during a routine exam. 

We looked at the file and the Plan's rules. In this case you had a medical eye exam. Refractions provided during medical eye exams are not covered. Based on this information, we decided that the Plan's rules for coverage of the medical eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no intravenous medications required or complex wounds at time of discharge. Daily skilled services are not required. You are ambulating 35 feet with a rolling walker with contact guard assistance and stand-by assist for transfers. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a stent placement procedure performed on September 16, 2021.  

You asked the Plan to waive the copayment for the stent placement. You say that you have not had a copayment for stent placement before. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each outpatient surgery. Separate cost sharing of $40 per visit may apply for specialist services.    

The file shows that you were not charged for the surgery, but the specialist services copayment was applied. Therefore, you have been asked to pay a $40 copayment for the stent placement. The stent placement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a stent placement procedure performed on September 16, 2021.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 he is 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OneTouch brand test strips.  You asked the Plan to pre-approve the OneTouch brand test strips. You say that the OneTouch strips are medically necessary. The Plan denied your request. The Plan says this brand of test strips are non-covered.  The Plan must follow Medicare rules. The rules state that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands.  We looked at the file and Medicare rules. There was no medical documentation provided to show that the plan's preferred brands of test strips would not meet the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of the OneTouch brand test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch brand test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical trays rendered on September 11, 2021.  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 the services are not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code A4550 (surgical trays) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical trays rendered on September 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services provided from May 12, 2021, to September 29, 2021, by an LPC.  You asked the Plan to pay for the LPC services. You say that the enrollee has a long-standing relationship with this counselor and changing providers would be detrimental to their health. The Plan denied your request. The Plan says the provider of these services (an LPC) is not a valid or recognized provider type for Medicare.  The Plan must follow Medicare rules. Medicare rules say that Medicare only recognizes the following provider types to bill outpatient mental health services: physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, certified nurse-midwives, and independently practicing psychologists. LPCs are not valid provider types under Medicare for providing outpatient mental health services.      We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LPC services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided from May 12, 2021, to September 29, 2021, by an LPC.