Persius/hicric huggingface dataset:
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 enrollee needs the intensive therapy to get back to the way she was prior to her surgery. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for admission to IRF.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: 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 enrollee's needs can only be met at an IRF, and these services are medically necessary for the enrollee to make a full recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in a lower level of care.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided July 7, 2021 to July 14, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you had called both the provider and the Plan to receive approval. You had called the Plan and was told that the provider was on the approved list so you do not understand the denial. The Plan denied your request. The Plan says the provider is a licensed independent mental health practitioner and is not eligible to bill Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided July 7, 2021 to July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on March 4, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $5 copayment for urgently needed services.   You have been asked to pay a $5 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on July 9, 2020.  You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you were never charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 specialist visit for outpatient hospital services.   You have been asked to pay a $15 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital 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 an outpatient hospital facility visit provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF stay. The Plan denied your request. The Plan says according to the information reviewed on appeal, the requested service is not medically necessary.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown and core buildup for tooth #5 provided on May 10, 2021.  You asked the Plan to pay for the crown and core buildup. You say that the doctor advised there was greater than 50% tooth loss and a crown was necessary. The Plan denied your request. The Plan says the records do not show over 50% of the tooth is lost.  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 crown and core buildup 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 pay for the crown and core buildup. Our reviewer says that although a crown is a possible alternative treatment, it does not meet the policy criteria for necessity. Our physician reviewer found that the provided photos and x-ray reveal substantial remaining structure, with more than 50% of the tooth remaining. The tooth would be restorable with a conventional restorative as the mesial of the tooth and cusps are still intact. Our reviewer also says that core buildup is not covered since the crown is not approved.  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 crown and core buildup have not been met. Therefore, we decided that the Plan does not have to pay for the crown and core buildup for tooth #5 provided on May 10, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on April 1, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because the enrollee was admitted to the hospital and the copayment should be waived. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care for emergency care.   The enrollee received emergency care on April 1, 2021. Therefore, the enrollee is responsible to pay the $90 copayment. Please note, this is a lesser amount than inpatient hospital charges and is in the enrollee's financial favor.   The enrollee has been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on May 18, 2021.  You asked the Plan to pay for the transportation service. You say that the response team came and checked your vitals. You say that there was no reason for you to go to the emergency room. You also say that you feel this claim should be paid. The Plan denied your request. The Plan says there was no transport provided. The Plan also says that since there was no transport provided, there is no payable service.  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 May 18, 2021. 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 the ambulance response and treatment, no transport, (A0998) provided on May 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided on February 24, 2021.  You asked the Plan to pay for ambulance 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 ambulance services provided on February 24, 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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.  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 based upon the available records, the enrollee is medically stable with no medical complexity and does not require physician supervision three times per week in an IRF. The enrollee has no acute rehab nursing needs. Based on her current level of function, she does not require intensive therapies, consisting of at least three hours of therapy at least five days per week with a multidisciplinary approach to daily therapy. With the enrollee's level of weakness and heavy dependence for mobility, there no expectation that the enrollee will make significant progress in an IRF. IRF admission is not medically necessary in this case. While the enrollee may benefit from physical and occupational therapies, her rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the sleep study (95806) provided on August 5, 2021.  You asked the Plan to waive the coinsurance for the sleep study. You say that you contacted the provider and they said they would waive your cost. You are on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly, and the cost-share was assessed in accordance with your 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 20% coinsurance for sleep studies.   You have been asked to pay 20% coinsurance for the sleep study. The provider billed $329 for the study, and the Plan's allowed cost for this service is $325. You have been asked to pay $65 ($325 x 20% = $65). 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 sleep study (95806) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray provided on June 24, 2021.  You asked the Plan to pay for the complete series x-ray. You say that you didn't know what the dentist required to provide you dentures and you were unaware the imaging would not be covered. You say that you shouldn't have to pay for someone else's mistake, and you do not have the ability to pay. The Plan denied your request. The Plan says reimbursement has already been issued for one full mouth x-ray.  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, you also have a maximum benefit of one complete series x-ray every five years. The Plan paid for the complete series x-ray provided on February 24, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an osseous surgery (D4260) provided by a participating provider on July 13, 2021.  You asked the Plan to pay for an osseous surgery. You say that you believe these services should be covered. The Plan denied your request. The Plan says the dental work requested 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 an osseous surgery (D4260) provided by a participating provider on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from July 1, 2021, through July 4, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were told you couldn't bring your own medicine and it had to be given by the hospital pharmacy. You say that you should not have to pay for this since you were prepared to take your own medicine. The Plan denied your request. The Plan says self-administered drugs are not paid when submitted on outpatient claims.   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 pay for the self-administered drugs provided from July 1, 2021, through July 4, 2021.   Benefits for the self-administered drugs 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 the enrollee cannot perform daily tasks to care for himself, and IRF care is medically necessary to return the enrollee to his prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services and therapy in an alternate setting.  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 based on a review of the available records, the enrollee is medically stable with no medical complexity and does not require physician supervision three times a week in an IRF. He has no acute rehab nursing needs. Based upon the enrollee's current level of function, he does not require intensive therapies, consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. The enrollee is not following commands consistently, fatigues easily and with baseline Dementia with added encephalopathy, is unlikely to make a significant progress in an IRF and retain the learned skills for function. IRF admission is not medically necessary. While the enrollee may benefit from physical, speech, and occupational therapies, his rehab needs can be safely met in an alternate and lower intensity setting such as a skilled nursing facility.  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.