Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 3, 2021, to July 16, 2021.  You asked the Plan to waive the copayment for the inpatient care. You say that you are still sick and cannot afford this copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with the contract.  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 $295 copayment for each of the first six days of an inpatient hospital stay. There is a $0 copayment for days 7-90.   You have been asked to pay a $1,770 copayment for the inpatient hospital stay which exceeded six days ($295 x 6 = $1,770). 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 hospital admission and services provided from July 3, 2021, to July 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 2, 2021, to July 30, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the RAP was not submitted within 5 days of the episode start date.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that this episode of care began on July 2, 2021. The record also indicates that the RAP was not submitted until August 27, 2021. This is outside of Medicare's allowable timeframe. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 2, 2021, to July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and drugs or medicaments dispensed in the office for home use (D9630) provided on September 10, 2021.  You asked the Plan to pay for the topical application of fluoride varnish and drugs or medicaments. You say that you only received a normal cleaning. The Plan denied your request. The Plan says these services are not covered under your plan.  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 topical application of fluoride varnish (D1206) and drugs or medicaments dispensed in the office for home use (D9630) provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), three pontics (D6245 x3), four retainer crowns (D6740 x4), and removal of residual tooth roots (D7250) provided on August 11, 2021.  You asked the Plan to pay for the core buildup, pontics, retainer crowns, and removal of residual tooth roots. You say that you believe these services should be covered. You also say that you have already paid $3,500 and cannot pay more than that. The Plan denied your request. The Plan says these services are not covered by your dental plan.  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 core buildup, including any pins when required (D2950), three pontics (D6245 x3), four retainer crowns (D6740 x4), and removal of residual tooth roots (D7250) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 2, 2021.  

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not covered by your plan. The Plan also says that your dentist has provided a copy of a treatment plan signed by you, in which you accepted financial responsibility for the services rendered as insurance would not be covering these services.  

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 problem focused limited oral evaluation (D0140) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for external electrocardiographic recording (procedure code 93244) provided to the enrollee on June 29, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the diagnosis code does not substantiate the service.  The Plan must follow Medicare rules. Medicare rules say that Current Procedural Terminology (CPT) 93244 is not covered.  The services were billed with CPT 93244. This is not a covered code in this situation. 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 pay for external electrocardiographic recording (procedure code 93244) provided to the enrollee on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a therapeutic continuous glucose monitor.  You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met.  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.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied coverage based on the understanding that the enrollee does not satisfy the specific coverage requirements for therapeutic continuous glucose monitors. However, no medical records were included in this appeal to provide us with information regarding the enrollee's clinical situation. We sent out a request to the Plan to reach out to the enrollee's provider for medical documentation that would support the request. A response to this request for information was never received. It is the burden of the Plan to make a reasonable and diligent effort to gather and forward information necessary.  Therefore, we decided that the Plan has to pre-approve a therapeutic continuous glucose monitor.   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 pre-approve prostate artery embolization services.  You asked the Plan to pre-approve prostate artery embolization services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure remains experimental/investigational for the enrollee's condition.  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 prostate artery embolization services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has benign prostatic hypertrophy with lower urinary tract symptoms. The requested service has not been shown to be safe and efficacious for the enrollee's clinical condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization services have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from March 31, 2021, to April 6, 2021, in another country.  You asked the Plan to waive the copayment for the inpatient care. You say that you paid for these services out-of-pocket and were expecting full reimbursement. You are upset that you were reimbursed $255.23 for these services. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with your contract. The out-of-country care was determined to be medically necessary and met criteria in this case. The services are covered, but you are responsible for a $450 copayment for each of the first four days of inpatient hospital care. You have been reimbursed the Plan's allowed amount for these services with your $1,800 copayment ($450 x 4 = $1,800) 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 $450 copayment for each of the first four days of inpatient hospital care. There is a $0 copayment for each Medicare-covered day for days five and beyond.  You paid for the out-of-country hospital care with foreign currency out-of-pocket at the time of service. The Medicare allowed amount for the services provided is $2,055.23. The Plan applied your $1,800 inpatient care copayment to these services and reimbursed you $255.23 ($2,055.23 - $1,800 = $255.23). This means that you have been reimbursed and 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 hospital admission and services provided from March 31, 2021, to April 6, 2021, in another country.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided on April 5, 2021.  

You asked the Plan to pay for the non-emergency ambulance transport. You say that you used ambulance transport from Florida back to Tennessee and your claim was denied. The Plan denied your request. The Plan says the ambulance requirement for transporting locally is not met and you were transported to another state. The Plan also says that Medicare does not cover non-emergent private pay ambulance transport.  

The Plan must follow Medicare rules. Medicare rules say that an ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a computed tomography scan or cobalt therapy) as well as the return transport. Medicare rules also say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided on April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy provided on October 13, 2021.  You asked the Plan to waive the copayment for the physical therapy. You say that you should not have to pay a copay. The Plan denied your request. The Plan says the cost share 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 $35 copay for outpatient rehabilitation services.      You have been asked to pay a $35 copay for the physical therapy. This service falls within the outpatient rehabilitation services 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 physical therapy provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Cyclobenzaprine 10 mg tablet.  

You asked the Plan to pre-approve Cyclobenzaprine. You say that this drug is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine 10 mg tablet.   

Benefits for Cyclobenzaprine 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: 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 weakness, hypoglycemia, and renal failure. 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 patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from August 20, 2021, to August 29, 2021.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was not receiving any skilled services.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility (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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 20, 2021, to August 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care for the elective total knee arthroplasty (CPT code 27447).  You asked the Plan to pay for acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says you are medically stable and have been provided medical clearance to undergo this elective procedure. The Plan states the procedure is not listed on the CMS Inpatient Only List, and the procedure is currently approved as an ambulatory procedure. The Plan state there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay; however, if you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.   The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found recent notes state that you have hyperlipidemia and atrial fibrillation. The surgery was approved. The records stated that the surgeon was planning the surgery and preoperative testing was underway, but no results of such were provided to suggest you were not cleared for surgery. This procedure is typically ambulatory and there was no indication you would likely require hospital services that would likely cross two (2) midnights based on the provided documentation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care for the elective total knee arthroplasty (CPT code 27447).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from May 23, 2021, to June 21, 2021.  

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 23, 2021, to June 21, 2021.