Persius/hicric huggingface dataset:
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 September 25, 2020, to September 30, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should have
been billed for these services in 2020, so you do not think you should be liable. 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 $300
copayment per day for days 1-4, and a $0 copayment for days 5-90 for inpatient hospital care.
Records show that you were in the hospital for five days. You were charged a $300 copayment per day for
each of the first four days, for a total of $1200. This cost sharing applies regardless of when you are billed. 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 September 25,
2020, to September 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the occupational therapist is recommending you get
inpatient therapy care so you can work on becoming independent again. The Plan denied your request. The
Plan says the stay is not medically necessary based on SNF criteria. The Plan states your needs can be met with
services such as, home health services and supervision at home.
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 identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. 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 SNF 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vestibular function testing you received
on January 5, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the vestibular function testing. You say that you should only
have to pay a $50 copayment for a specialist. 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 $100
copayment for diagnostic tests at an outpatient hospital facility.
You received vestibular function testing, not just an office visit. The records also show that the facility where
you received this testing is considered an outpatient hospital facility. You have been asked to pay a $100
copayment for the vestibular function testing. 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
vestibular function testing you received on January 5, 2021, at an outpatient hospital facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G.
You asked the Plan to pre-approve a MyoPro 2 Motion G. You say that the requested MyoPro 2 Motion G is
medically necessary. The Plan denied your request. The Plan says the requested MyoPro 2 Motion G is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a MyoPro 2 Motion G. Our reviewer
says that the requested MyoPro 2 Motion G is not medically necessary. Our physician reviewer found the
powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s),
includes microprocessor, sensors, all components and accessories, custom fabricated (L8702) is not medically
necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). At this time the requested
robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of
hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke
hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and
botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or
treatment of an illness or injury or to improve the functioning of a malformed body member.
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the
long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is
insufficient evidence in the literature that this device will increase participation in bimanual activities.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a MyoPro 2 Motion G have not been met. Therefore, we decided that the Plan
does not have to pre-approve a MyoPro 2 Motion G
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve acupuncture. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, you do not meet the coverage criteria for covered
acupuncture services. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair (K0825) and accessories (E2361 and E1028).  You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power wheelchair (K0825) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair (K0825).  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair (K0825). Our physician reviewer found the enrollee has a mobility deficit but the DME consultation reveals that the enrollee is able to perform most of her basic instrumental activities of daily living without assistance but with some instability. The consultation states that the enrollee's mobility deficits can be helped by a 4 wheeled walker with a heavy-duty seat. The evaluation states that the enrollee is a functional ambulator within the home with her walker and consistent use of the walker would allow her to safely participate in her basic and instrumental activities of daily living. Therefore, powered mobility is not medically necessary for in-home use and will not significantly improve mobility related activities of daily living participation in the home.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0825) and accessories (E2361 and E1028).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 IRF admission is not medically necessary based on lack of medical complexity and nursing needs. Functionally at the level you are in, you should be discharged and not admitted to an IRF. Document does not support the necessity for admission.  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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN)
(G0299) provided from April 29, 2020, to May 20, 2020.
You asked the Plan to pay for the direct skilled nursing services. You say that these services were medically
necessary. The Plan denied your request. The Plan says the services were not medically necessary.
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 pay for the direct skilled nursing services. Our
reviewer says that the requested home health services were not medically necessary. Our physician reviewer
found the documentation does not support that the enrollee required skilled nursing services to provide
treatment that was medically necessary from April 29, 2020 through May 20, 2020. Our reviewer found that
the enrollee did not require additional skilled nursing services to effectively provide treatment, care, and/or
services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's
condition and/or prevent deterioration. Our physician reviewer also found that the enrollee had been medically
stable without any recent exacerbations of chronic medical problems or hospitalizations.
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 direct skilled nursing services have not been met. Therefore, we decided that
the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided from April 29, 2020, to May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided on March 14, 2021.
You asked the Plan to pay for the initial hospital care services. The Plan denied your request. The Plan says
with the information provided it could not be determined how the enrollee came to the servicing provider, or
whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. The record shows that the Plan attempted to obtain records multiple
times, but they were not provided. Based on this information, we decided that Medicare rules for coverage of
the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay
for the initial hospital care services provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest you received on August 21,
2020.

You asked the Plan to waive the coinsurance for the LifeVest. You say that you were told you wouldn't have to
pay for this. 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 durable medical equipment.

You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical
equipment 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 LifeVest you received
on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first 30-74 minutes (99291) provided April 4,
2021 to April 25, 2021.
You asked the Plan to pay for the critical care services. You say that please find the requested medical records.
you appreciate reconsideration for payment of the services rendered. The Plan denied your request. The Plan
says requested information was not provided timely or was insufficient or incomplete.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99291 is evaluation and management of the critically ill
or critically injured patient, first 30-74 minutes).
We find that CPT code 99291 is not supported in the medical record. Specifically, critical time was not
documented. Medical records are still needed that support critical care, first 30-74 minutes. Based on this
information, we decided that Medicare rules for coverage of the critical care services have not been met.
Therefore, we decided that the Plan does not have to pay for critical care, first 30-74 minutes (99291) provided
April 4, 2021 to April 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on September 2, 2021.
You asked the Plan to pay for the resin-based composites. You say that you called at the end of August and was
advised you had coverage for fillings. The Plan denied your request. The Plan says the service is not a covered
benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composites provided on September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physical therapy provided by an out-of-
network provider March 25, 2021, to March 29, 2021.
You asked the Plan to waive the coinsurance for physical therapy. You say that you do not feel like you should
be liable for this. The Plan denied your request. The Plan says the correct coinsurance has been 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 a 50%
coinsurance for outpatient rehabilitation services/out-of-network.
You have been asked to pay a 50% coinsurance of the allowed amount for physical therapy. The total allowed
amount is $146.02. The total amount you are being asked to pay is $73.00 ($146.02 x 50% = $73.00). Physical
therapy falls within the outpatient rehabilitation services/out-of-network 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 physical therapy provided by an out-of-network provider
on March 25, 2021, to March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6752), and pontic (D6242) provided
on July 19, 2021.
You asked the Plan to pay for the fixed prosthesis. You say that you were reimbursed $25 for the oral
evaluation. You also say that you had to pay over $600 for the fixed prosthesis. The Plan denied your request.
The Plan says fixed prosthesis are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the fixed prosthesis is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns
(D6752), and pontic (D6242) provided on July 19, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scan provided on July 16, 2021.

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says that no modifiers are allowed for this code pair.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

We looked at the file and the rules. In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without contrast material. We find that code 70450-59 was billed with code 70460. The records show that no payment was made for code 70460. Which means that the code at issue, 70450, cannot be considered inclusive to code 70460. The medical records also show that a CT angiography (code 70496), was also provided on the date of service at issue. Both codes 70450 and 70460 would be considered a column II code. Since the records support the use of modifier -59 to bypass an edit with 70496, denying payment for the Column 2 code is not appropriate in this case. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan provided on July 16, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient injection procedure you had at an outpatient hospital facility on June 9, 2021.  You asked the Plan to waive the copayment for the outpatient injection procedure. You say that normally you would go to the doctor's office to get this injection.  You stated that had you known of the cost sharing, you would not have had this done at the facility. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($269.66) is less than your copayment obligation, you are responsible for the full allowed 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 $350 copayment per visit for outpatient surgery and other services at a hospital outpatient facility.   You have been asked to pay a $350 copayment per visit for the outpatient injection procedure. The outpatient injection procedure falls within the outpatient surgery and other services at a hospital outpatient facility 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 outpatient injection procedure you had at an outpatient hospital facility on June 9, 2021.