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

We decided that the Plan does not have to pay for continuation of SNF services provided from
February 23, 2021, through February 25, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says there were no daily skilled needs.
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 pay for continuation of SNF services provided from February 23, 2021, through February 25, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She continued with yelling behaviors and her medications were adjusted. She was evaluated for a fall without fracture. Regarding rehabilitation services, the enrollee received speech therapy in the SNF at a non-skilled level for a diet upgrade. By the dates in question, the enrollee was independent with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does 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 continuation of SNF services provided from February 23, 2021, through February 25, 2021. have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from February 23, 2021, through February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services from October 18, 2020, to October 22, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you would like the Plan to cover the bills. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $335 copayment each day for days 1 to 5 for Medicare-covered hospital care. You have been asked to pay a total of $1,340 ($335 copayment x 4 days = $1,340) for the inpatient stay. This inpatient stay falls within the Inpatient hospital 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 inpatient admission and services from October 18, 2020, to October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fusion of pelvic joint using imaging guidance (27279).
You asked the Plan to pre-approve fusion of pelvic joint using imaging guidance. You say that this procedure is medically necessary. The Plan denied your request. The Plan says more information about the enrollee's diagnosis and planned surgery is needed including imaging scans and test results.
The Plan follows Medicare rules. Medicare rules say that the requested sacroiliac joint fusion surgery 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 fusion of pelvic joint using imaging guidance. Our reviewer says that the requested surgery is not medically reasonable and necessary. Our physician reviewer found that the Medicare criteria for coverage have not been met. In this case, a complete workup for the requested surgery has not been completed at this time. Hip degenerative joint disease and pain from previous fusion not ruled out. In addition, prior injection results do not show adequate pain relief. SI joint fusion not medically 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 fusion of pelvic joint using imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve fusion of pelvic joint using imaging guidance (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) provided June 22, 2020.
You asked the Plan to pay for the abutment support crown. You say that you feel that excluding crowns mounted on implants is arbitrary and a poor dental care policy. The Plan denied your request. The Plan says this service is not covered under your 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 abutment supported porcelain/ceramic crown (D6058) provided June 22, 2020.
Your complaint about which services are covered under the Plan's dental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on February 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99214, 96372, G0454) provided on August 21, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available for these non-emergent 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 physician services (99214, 96372, G0454) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied for a lack of medical necessity.
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 there is no documentation that she has failed standard anticholinergic drug therapy or that the enrollee demonstrates intolerance to the anticholinergic drug therapy despite best attempts at management of the most common side effects of such therapy, such as dry mouth and constipation. 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 percutaneous tibial nerve stimulation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment purchased on March 9, 2021.
You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for this equipment.
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. The contract also states that durable medical equipment requires prior authorization. The provider in this case is not a network provider. The Plan did not pre-approve the item. Therefore, we decided that the Plan does not have to pay for durable medical equipment purchased on March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for portable gaseous oxygen system provided on
February 25, 2021.
You asked the Plan to pay for portable gaseous oxygen system. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for portable gaseous oxygen system provided on
February 25, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthesis components (L5848, L5856).
You asked the Plan to pre-approve the prosthesis components. You say that the claim should be paid. The Plan
denied your request. The Plan says the prosthesis has been approved at the prior level, but L5848 and L5856
were not approved as they were not used in this prosthesis.
The Plan must follow Medicare rules. Medicare rules say that HCPCS codes L5848 and L5856 are not used to
build this knee and cannot be approved.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the prosthesis components have not been met. Therefore, we decided that the Plan does not have to
pre-approve prosthesis components (L5848, L5856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide the CPEP device.
You asked the Plan to provide the combination device chest wall oscillator with a continuous positive expiratory pressure device (E1399, A9900). You say that stopping use of the device will make it more difficult to breathe. The Plan denied your request. The Plan says there is no documentation that the device that combines therapies is superior to the individual BiPAP, CPAP, oscillation devices.
The Plan must follow Medicare rules. Medicare rules say the HFCWO devices are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide the combination device chest wall oscillator with a continuous positive expiratory pressure device (E1399, A9900).
Our reviewer says that the device is not medically necessary. Our physician reviewer found the requested device is considered not medically necessary for this patient who has severe COPD. This device combines nebulizer therapy, positive pressure, and airway flow oscillation. There is inadequate evidence to support the safety and efficacy of this device for treating COPD in the home setting. The denial is upheld. 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 combination device chest wall oscillator with a continuous positive expiratory pressure device (E1399, A9900). have not been met. Therefore, we decided that the Plan does not have to provide a CPEP device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 25, 2021.
You asked the Plan to pay for these services. You say that you do not believe you owe this bill because these services were approved. You provided a screen shot showing these services were approved. The Plan denied your request. The Plan says the provider in question is out of network and was not approved.
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 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 may have approved this service, but the Plan did not approve this provider. The "approval screen" that you submitted also does not list the provider in question as the approved provider. Therefore, we decided that the Plan does not have to pay for physician services provided on February 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 22, 2020 and October 27, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the service is not covered under the member's contract under any normal circumstances.
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 August 22, 2020 and October 27, 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 for ambulance response and treatment, no transport (A0998) provided on August 22, 2020 and October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479, 81408, 81407, 81345, 81302, 81223) provided September 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing for Cystic Fibrosis, 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 lab services (81479, 81408, 81407, 81345, 81302, 81223) provided September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided May 5, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you had issues obtaining services and you are dissatisfied with your coverage. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the intraoral x-rays once every three years. We looked at the file and Medicare rules. The Plan provided documentation that a complete series of intraoral x-rays was already covered on the same day. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided May 5, 2021.
Your complaint about you dissatisfaction with the Plan's coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on May 6, 2021.
You asked the Plan to pay for these services. You say that this service should be covered the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on May 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on November 7, 2020.
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided on November 7, 2020.