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 you need additional care because you are afraid you
could hurt yourself. The Plan denied your request. The Plan says IRF admission 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 your 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 you 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on November 4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the Genesight panel. You say that this is a covered test per a Medicare Local Coverage Determination. The Plan denied your request. The Plan says this testing was ordered by a noncontracted nurse practitioner and provided by an OON laboratory. Since no authorization was requested for these services, the denial is correct.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on November 4, 2020 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348).
You asked the Plan to pre-approve the retreatment of previous root canal therapy. You say that you need this
service rendered because of a possible infection that can affect your brain if it is not taken care of. The Plan
denied your request. The Plan says this service is not covered under your benefit package.
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 pre-approve a
retreatment of previous root canal therapy (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit.
You asked the Plan to waive the deductible for an office visit. You say that you were charged for the annual wellness check office visit. You also say the annual check-up is free and you should be reimbursed that amount. The Plan denied your request. The Plan says you have been charged 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 Plan contract says that there is a $600 deductible for all items and services except those specifically excluded by the Plan contract. You have been asked to pay a $152.03 deductible for an office visit. The records show the services provided went beyond the scope of an annual wellness checkup. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $600 deductible, which applies to Physician/Practitioner Services, Including Doctor's Office Visits. 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 that had not been met at the time of the office visit on April 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation surgery.
You asked the Plan to pre-approve percutaneous vertebral augmentation surgery. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for the requested procedure have not been met.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation surgery is subject to the criteria listed 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 percutaneous vertebral augmentation surgery. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that in this case, the documentation provided does not portray adequate conservative measures to include a trial of bracing. Before this procedure will be approved for coverage, adequate conservative measures must be demonstrated that fail to improve the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens provided to you on April 27, 2021.
You asked the Plan to pay for the astigmatism correcting function. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. While the Plan does cover the IOL after cataract surgery, the astigmatism correcting function is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens provided to you on April 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided on October 29, 2020.
You asked the Plan to pay this claim a second time. You say this claim was paid and then recouped by the Plan. You say this claim should be paid as the enrollee did not enter hospice until after the transport.
The Plan denied your request. The Plan says due to the enrollee's hospice election, this claim was paid in error. The provider must submit the claim to Original Medicare first for review. Once Original Medicare either pays or denies the transport, they will send an Explanation of Benefits to the Plan. At that point the Plan will address any payment obligation for the transport.
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 date in question. Therefore, all services provided on that date must be submitted to Original Medicare first for review. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 29, 2021, through April 8, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be responsible for the cost share. 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 $300 copayment per day one through five for inpatient hospital care. You have been asked to pay a $300 copayment per day one through five for inpatient hospital care. inpatient hospital care 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 inpatient hospital care provided on March 29, 2021, through April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power lift recliner chair purchased from a provider that is not certified with Medicare on December 18, 2020.

You asked the Plan to pay for the power lift recliner chair. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says payment to a provider not certified with Medicare is not allowed.

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 power lift recliner chair purchased from a provider that is not certified with Medicare on December 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does require skilled therapy services, but not on a daily basis or in an inpatient 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
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)
provided on April 26, 2021.

You asked the Plan to pay for the core buildup. You say that a core buildup is appropriate when a tooth is too
damaged to support a crown. You also say that since the installation of a crown is a covered benefit, the core
buildup should be paid as an integral part of the crown installation process. The Plan denied your request. The
Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of
service to verify benefits and provider eligibility.

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) provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional services. You say that the enrollee needs to increase strength and endurance. The Plan denied your request. The Plan says the documentation does not support a need for a skilled therapist.

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 services. Our physician reviewer found that the enrollee needs assistance turning and transitioning. He is independent in gait on flat ground but unable to ambulate outside safely or in community.

The additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. He has had prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. He has been instructed in a home exercise program. The requested services are not part of a maintenance program. The specialized skill, of a qualified therapist is not required to establish, design and/or deliver a program to maintain his 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 16, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that since this was a non-emergency transfer between facilities you should not have to pay the copay. The Plan denied your request. The Plan says that you were assessed the 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 $220 copayment for each one-way Medicare-covered ground ambulance trip. 

You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground ambulance trip 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 ambulance transport provided on April 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT colonography screening for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says a CT colonography requires colonic preparation similar to that required for a standard colonoscopy.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee underwent an instrument colonoscopy in 2018 to the level of the cecum but had a poor bowel preparation. The record does not indicate that a repeat instrument colonoscopy is not indicated. The record does not indicate that there is a contraindication to instrument colonoscopy. The bowel preparation is similar for both studies. The elements of the coverage determination 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 the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT colonography screening for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits and a stool analysis for blood provided from April 15, 2021, to May 31, 2021.

You asked the Plan to waive the copayments for office visits and a stool analysis for blood. You say that you feel that the services should be considered preventative and you 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 $10 copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay a $10 copayment for lab services.

The medical records show that you had an office visit that went beyond an annual wellness exam on April 15, 2021. Therefore, you are responsible to pay the $10 copayment. 

The medical records show that you had an office visit that went beyond an annual wellness exam on May 25, 2021. Therefore, you are responsible to pay the $10 copayment.

The medical records show that you received a stool analysis for blood on May 31, 2021. The code submitted does not fall under a preventative service. Therefore, you are responsible to pay the $10 copayment.
  
The total amount you owe is: $30.

You have been asked to pay the total copayment amount of $30 for office visits and a stool analysis for blood. Office visits falls within the physician/practitioner services, including doctor's office visits benefit category. A stool analysis for blood falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for office visits and a stool analysis for blood provided from April 15, 2021, to May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper left and
lower left quadrants.
You asked the Plan to pre-approve the dental services. You say that you were charged for this service
previously. You say that the work was not done, or definitely not done successfully. You also say that you had
to find a new provider that is able to do the procedure. The Plan denied your request. The Plan says scaling and
root planing is covered once every 24 months, per quadrant. The Plan also says that the frequency limit has
been reached.
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 the services are listed as covered,
the frequency limit has been reached. The record shows that the Plan paid for scaling and root planing for the
upper left and lower left quadrants that you received on March 24, 2021. Therefore, we decided that the Plan
does not have to pre-approve scaling and root planing (D4341) for the upper left and lower left quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a colectomy provided on March 9, 2021.

You asked the Plan to waive the coinsurance for a colectomy. You say that you disagree with the charges
because the procedure should be considered coronavirus testing. 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 20%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.

You received a colectomy at an outpatient hospital facility on March 9, 2021. This is not considered
coronavirus testing. A colectomy is considered an outpatient surgical procedure. The total allowed amount is
$4.550.35 and 20% of that is $910.07.

You have been asked to pay the total coinsurance amount of $910.07 for a colectomy. A colectomy falls within
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colectomy provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hand controls, Sure Grip multifunction switch

You asked the Plan to pay for the hand controls. You say that you had to incur the cost of the Sure Grip hand control installed on your vehicle because without them you would be restricted from being able to operate your vehicle and would not be able to drive. The Plan denied your request. The Plan says this item is not covered as it is a self-help device and does not primarily serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for hand controls, Sure Grip multifunction switch