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

We decided that the Plan does not have to pay for the physician services provided on November 11, 2020.

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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, there were no medical records provided to verify the services were billed correctly per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the physician services provided on November 11, 2020.
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 review of facility records show that you have been unable to participate
in most therapy sessions offered there.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from September 13, 2020, to September 17, 2020.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the billed diagnosis code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 the services. Our reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician reviewer found that the enrollee presented with dyspnea and cough. He was afebrile, hemodynamically stable, and hypoxic (88% saturation). There was a leukocytosis, creatinine of 2.1 (known CKD related to diabetic nephropathy), anemia, and negative coronavirus test. The enrollee was treated with IV antibiotics, IV steroids, Duonebs, and supplemental oxygen. At no time was there hemodynamic instability or acute organ decompensation. The clinical documentation did not support that the billed diagnosis impacted this hospital admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from September 13, 2020, to September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air-fluidize bed from Ethos Therapy Solutions to be billed under code E1399.
You asked the Plan to pre-approve an air-fluidize bed from Ethos Therapy Solutions to be billed under code E1399. You say that the requested item is necessary. The Plan denied your request. The Plan says the requested code E1399 has been correctly denied due to miscoding.
The Plan must follow Medicare rules. Medicare rules say that that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an air-fluidize bed from Ethos Therapy Solutions to be billed under code E1399 have not been met. An air-fluidize bed from Ethos Therapy Solutions billed under code E0194 has been approved by the plan. Therefore, we decided that the Plan does not have to pre-approve an air-fluidize bed from Ethos Therapy Solutions to be billed under code E1399.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick external catheter.
You asked the Plan to pre-approve incontinence supplies. You say that the ad said that it was covered by Medicare. The Plan denied your request. The Plan says the PureWick System external catheter is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick external catheter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a medical eye exam (92014) provided on April 30, 2021.

You asked the Plan to reduce the copayment for a medical eye exam. You say that you were seen for a routine eye exam and you should not be charged for this service. The Plan denied your request. The Plan says in addition to the annual eye exam, this visit was for a medical condition, therefore, the copayment you are being charged is correct.

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 pay $15 for one annual routine eye exam. If you receive services that address a medical condition during the same office visit, you pay a $40 specialist office visit copayment.

You have been asked to pay a $40 copayment for a medical eye exam. The records show that you had an annual eye exam that addressed a medical condition. The EOC confirms $40 is the required copayment for this service. A medical eye exam 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 reduce the copayment for a medical eye exam (92014) provided on April 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you could use at least 10 days of physical therapy but would like to do up to 30 days of physical therapy if you could. The Plan denied your request. The Plan says your condition does not meet the requirements for a SNF admission.
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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 15, 2020 by a nonparticipating
provider.
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 rendered by a non-participating 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 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 on October 15, 2020 by a
non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided on June 11, 2021.

You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that you have to use nitrous. You also say that you cannot afford to pay for this service out of pocket. The Plan denied your request. The Plan says benefits for this service are not available.

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 contract says that facility and/or facility anesthesia services associated with a dental procedure are covered only if the primary dental procedure is covered under the guidelines of Original Medicare. Resin-based composites (fillings) are clearly listed as non-Medicare covered (or supplemental) dental services, and are not considered to be Medicare-covered. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on June 2, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you were told this vaccine was necessary as you will be turning 70 years old. You feel this means it should be covered. The Plan denied your request. The Plan says this is not covered by Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on June 2, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 1, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the SNF care. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 1, 2020, 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 rendered on October 5, 2020.
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 testing is not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a removal of residual tooth roots (D7250) of tooth #20.
You asked the Plan to pre-approve the removal of residual tooth roots. You say that the enrollee wants to remove their broken teeth because they are in pain on their left side. The Plan denied your request. The Plan says that this procedure is not medically necessary.
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 removal of residual tooth roots when the services are medically necessary and reasonable. 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 removal of residual tooth roots. Our reviewer says that the documentation provided meets the criteria for coverage for removal of the residual root of tooth #20 via procedure code D7250. Our physician reviewer found the clinical crown of tooth #20 is decayed and fractured leaving the root encased in bone. Our reviewer also found that that due to the compromised coronal structure, forceps removal would be not possible and a cutting procedure and bone removal are most likely required for the root removal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the removal of residual tooth roots have been met. Therefore, we decided that the Plan has to pre-approve a removal of residual tooth roots (D7250) of tooth #20.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Botox injections provided to the enrollee on March 3, 2021.
You asked the Plan to pay for this treatment. You say that this claim should be paid. The Plan denied your
request. The Plan says the records do not show the enrollee had prior authorization for this treatment.
Medicare rules say that plans can require enrollees to get care prior authorization prior to a treatment. The Plan
contract says that while out of network services are permitted, they may need prior authorization. The Plan
contract shows Medicare Part B drugs require prior authorization. The Plan did not pre-approve the Botox
injection provided. Therefore, we decided that the Plan does not have to pay for Botox injections provided to
the enrollee on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on March 23, 2021.
You asked the Plan to waive the deductible for the laboratory work. You say that your plan deductible of $250 should be waived. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 which applies laboratory tests. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to laboratory tests.
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on March 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on March 23, 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 it is feasible to meet the member's needs at a lower level of care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on April 16, 2021.
You asked the Plan to pay for the refraction. You say that you called the Plan the day of your appointment and
was told this was covered. The Plan denied your request. The Plan says this is not a Medicare covered service.
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 and Medicare do not cover this service. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on May 3, 2021. You asked the Plan to waive the copayment for the telehealth visit. You say that this should be covered because you have had several telephone calls to doctors due to medical issues and have never been charged. You say you have a history of talking to doctors over the phone. The Plan denied your request. The Plan says you have been asked to pay 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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for the telehealth visit. The telehealth visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 telehealth visit provided on May 3, 2021.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted for chest pain. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.