Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of soft tissue (D7286), and excision of a
benign lesion, greater than 1.25 cm, (D7411) provided from July 29, 2021, to August 26, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered under your
optional supplemental dental coverage. You say that dental health should not be deemed any less important.
You also say that this should be covered. The Plan denied your request. The Plan says incisional biopsy of soft
tissue is not listed as a covered service. The Plan says that excision of a benign lesion is not listed as a covered
service either.
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 incisional biopsy of soft tissue an
excision of benign lesion are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to pay for the incisional biopsy of soft tissue (D7286), and excision of a benign lesion, greater
than 1.25 cm, (D7411) provided from July 29, 2021, to August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work to detect infectious agents
provided on February 19, 2020.
You asked the Plan to waive the deductible for lab services. You say that you are a widow living alone and
your only income for many years has been your Social Security Disability payments. You say you cannot
afford to pay this bill. The Plan denied your request. The Plan says the claim was processed correctly. The Plan
states you must pay your deductible in full before the Plan will pay their share of the services at issue.
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 $500 deductible which applies to Laboratory Services.
The item or service you asked the Plan to waive the deductible for falls within the Laboratory Services benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
deductible which applies to Laboratory Services.
This cost sharing is a contractual obligation that had not been met at the time lab services were received on
February 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for lab work to
detect infectious agents provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2394) for tooth # 5 provided on August 17,
2021.
You asked the Plan to pay for the dental service. You say that your insurance covers up to $3,000 for dental
services. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 2
fillings per calendar year are covered. The Plan also says that the frequency limit has been exceeded.
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 and fillings are listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for fillings for teeth # 3 and 4 that you
received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the
filling (D2394) for tooth # 5 provided on August 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says based on
Medicare guidelines, the SNF services that you and/or your provider are requesting do not meet the
requirements for approval.
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 medically necessary. Our physician reviewer found that the record indicates that the enrollee was a resident at an extended care facility and receiving reasonable and necessary skilled rehabilitation services five days a week due to deconditioning. The record does not indicate that the services could only be provided on an inpatient basis in a skilled nursing facility. The elements of the coverage criteria are not satisfied. 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 SNF services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on July 5, 2021, to
August 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the behavioral health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The
records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for behavioral health services provided on July 5, 2021, to August 30, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
October 12, 2021, to October 15, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have had several
hospital stays and your physician believes that you were discharged too soon. 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 $325
copayment for days 1-5 for inpatient hospital care.
The medical records show that you had an inpatient hospital stay from October 12, 2021, to October 15, 2021.
Therefore, you are responsible to pay a $325 copayment for days 1-3 (October 12, 2021, to October 14, 2021).
The total amount you owe is: $325 (copayment) x 3 (inpatient hospital care) = $975.
You have been asked to pay the total copayment amount of $975 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 12, 2021, to October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
is currently unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
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 inpatient rehab 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 necessary care can safely be provided 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on July 20, 2021.  You asked the Plan to pay for the dental service. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.  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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the
enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation on any physical exam of any lymphedema on the chest, trunk,
or abdomen, only in the extremities.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is noted to have lower extremity phlebolymphedema and morbid obesity. There is no
documentation of truncal edema. There is no evidence that the enrollee used a basic pump device (E0651) for
four weeks resulting in treatment failure or intolerance. Therefore, the documentation does not support that an
advanced leg pump (E0652) is currently medically necessary or reasonable.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. Based on the available records the enrollee appears to have improved with therapy to the point of being able to manage cleaning activities. Further skilled therapy beyond what has already been approved by the health Plan at this point does not appear likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate after completion of the additional six therapy sessions approved. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services provided on October 4, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the cytopathology services. You say that you are not required to get authorization
because you do not have access to the enrollee's insurance information. The Plan denied your request. The Plan
says no prior authorization was obtained.
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. The
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to
pay for cytopathology services provided on October 4, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the x-ray and office visit provided by in-network providers from August 19, 2021, to September 19, 2021.  You asked the Plan to waive the copayments for the x-ray and the office visit. You say that you should not be responsible for the copayments. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment per day, per provider for in-network Medicare-covered x-ray services and a $15 copayment for each in-network Medicare-covered visit with a primary care physician (PCP).   The enrollee has been asked to pay a $30 copayment for the x-ray and a $15 copayment for the office visit. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the x-ray and office visit provided by in-network providers from August 19, 2021, to September 19, 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 by coming home with the conditions you have could
be detrimental to your well-being. The Plan denied your request. The Plan says criteria for admission to the
Acute Inpatient Rehabilitation setting 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 the IRF admission is not medically necessary based on lack of medical complexity,
and rehab nursing needs. Our reviewer found that the documentation does not support the necessity for
admission to an IRF. Our physician reviewer also found that while you may benefit from physical therapy and
occupational therapy, your rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery pathology services provided on October 11, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for the surgery pathology services. You say that you work with a group of doctors
who are participating providers and use your laboratory exclusively. You say the enrollee does not go to the
laboratory, so they are not using out-of-network benefits. The Plan denied your request. The Plan says no prior
authorization was obtained.
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. The
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to
pay for surgery pathology services provided on October 11, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD
procedure)
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says the requested services are not eligible for coverage as the enrollee is not in an
approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed. Complications have been reported
with this experimental procedure.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve minimally invasive lumbar decompression (MILD procedure).