Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for foam dressing, wound cover, sterile (A6209) provided July 8, 
2021. 
 
You asked the Plan to waive the copayment for the wound care supplies. You say that you were advised by a Plan representative not 
to pay this bill. These have been paid for several years and you do not understand why the Plan won't pay anymore. The Plan denied 
your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
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% of the Plan allowed amount for 
Medicare covered durable medical equipment.  
 
You have been asked to pay $4.97 for the wound care supplies. The wound care supply falls within the Durable medical equipment 
(DME) and related 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 copayment for foam dressing, wound cover, sterile (A6209) provided July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided on January 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services is always bundled into payment for other services not
specified.
We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for
other services. No separate payment can be made for this service. 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 the services (99072) provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulp vitality test (D0460), a limited oral evaluation 
(D0140), a cone beam computed tomography (CT) capture (D0364) and retreatment of previous root canal 
therapy (D3346) provided on May 20, 2021, to June 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pulp vitality test, a limited oral evaluation, a cone beam CT capture and 
retreatment of previous root canal therapy. You say that you would appreciate consideration to your request for 
additional payment. You also say that the issue is more than a routine dental visit, but a painful incident that 
required special attention, that should be treated more seriously. The Plan denied your request. The Plan says 
you have exhausted your benefit for a limited oral evaluation. The Plan also says that the services at issue are 
not covered benefits of 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.  
 
We looked at the file and Medicare rules. The records show that you received reimbursement for two limited 
oral evaluations on January 6, 2021, and May 18, 2021, therefore, you have exhausted your maximum benefit 
for this service. The contract also confirms that a retreatment of previous root canal therapy, a cone beam CT 
capture and a pulp vitality test are not a covered benefit with Medicare or the Plan. Based on this information, 
we decided that the Plan's rules for coverage of pulp vitality test, a limited oral evaluation, a cone beam CT 
capture and retreatment of previous root canal therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for a pulp vitality test (D0460), a limited oral evaluation (D0140), a cone beam computed 
tomography (CT) capture (D0364) and retreatment of previous root canal therapy (D3346) provided on May 
20, 2021, to June 21, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs sub-acute rehabilitation. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound supplies provided on July 12, 
2021. 
 
You asked the Plan to waive the coinsurance for wound supplies. You say that a representative of the Plan 
advised you not to pay the bill in question. The Plan denied your request. The Plan says the correct coinsurance 
was 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 20% 
coinsurance for Medicare-covered durable medical equipment. 

You have been asked to pay $19.49, or 20% of the Medicare-allowed charge of $97.47, for wound supplies. 
Wound supplies fall within the "Durable medical equipment (DME) and related 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 coinsurance for wound supplies provided on July 12, 2021.  
 
Your complaint about receiving erroneous or incomplete information from a representative of the Plan about 
your cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided on December 31, 2019.
You asked the Plan to pay for SNF care. You say that the services provided were reasonable and necessary. The Plan denied your request. The Plan says that the documentation does not support the services that were rendered.
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 SNF care. Our reviewer says that the enrollee did meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan you 
had on April 26, 2021, and the visit you had with a radiologist on May 4, 2021. 
 
You asked the Plan to waive the copayments for the CT scan and the radiology visit. You say that these 
services were for pretesting for a surgery that never happened because the Plan cancelled your surgery. The 
Plan denied your request. The Plan says you were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for CT scans and a $35 copayment for specialist visits.  
 
You have been asked to pay a $100 copayment for the CT scan and a $35 copayment for the radiology visit.
These copayments apply regardless of the reason for the services. 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 the computed tomography (CT) scan you had on April 26, 2021, and the visit you had with a 
radiologist on May 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on
April 14, 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 there was no documentation of a consultation with the attending or primary care physician in the medical record.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. WWe find that CPT code 90832 is not supported in the medical record. Specifically, the record shows that the services were provided by a Clinical Psychologist without consultation from the enrollee's Primary Care Physician. 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 psychotherapy services provided to the enrollee on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided May 22, 2021.
You asked the Plan to waive the copayment for the emergency ambulance transport. You say that the transport was the result of an issue with a previous medical service, and you should not be responsible for the cost. The Plan denied your request. The Plan says the copayment is a contractual obligation and has been 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 $250 copayment for each one-way trip for Medicare-covered ambulance benefits.
You have been asked to pay a $250 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance 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 ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810) provided from March 5, 2021, to March 31, 2021.
You asked the Plan to pay for acupuncture. You say that the enrollee was not aware that acupuncture was only covered for chronic lower back pain. The Plan denied your request. The Plan says documentation shows that these services were provided to treat peripheral neuropathy of the lower extremities. Medicare only covers acupuncture for treatment of chronic lower back pain (CLBP). Acupuncture treatment of any other condition is not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture services were provided to treat a condition other than chronic lower back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810) provided from March 5, 2021, to March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from July 6, 2021, through July 13, 2021.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you were taken to the hospital against your will. The Plan denied your request. The Plan says the copayment 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 $275 copayment per day for days 1-5 for inpatient mental health care. You have been asked to pay a $1375 ($275 x 5 = $1375) copayment for inpatient mental health care. The services at issue fall within the inpatient mental health 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 mental health care provided from July 6, 2021, through July 13, 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 right reverse shoulder arthroplasty with tenodesis (CPT code 23472), for the enrollee.
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 the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences 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 the review has determined that the record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnights. 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 right reverse shoulder arthroplasty with tenodesis (CPT code 23472), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64415, 99135) provided on January 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. In this case, we have confirmed that code 64415 has a bundled relationship with code 01630 and 
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have 
not been met. Additionally, code 99315 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this 
is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 
99315. Therefore, we decided that the Plan does not have to pay for the services (64415, 99135) provided on January 22, 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 you do not have the support at home to manage. The 
Plan denied your request. The Plan says criteria for admission to the IRF 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (22869, 22870).
You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that the enrollee meets medical necessity criteria for this service. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the vertiflex device is experimental. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a safety risk and needs to be in physical therapy. The Plan denied your request. The Plan says the enrollee does not have skilled nursing or rehabilitation needs that need to be provided on a daily basis as an inpatient.
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 necessary. Our physician reviewer found that the enrollee does not require skilled nursing services of a skilled professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. The enrollee's functional level does not require the services of a qualified therapist to provide medically necessary treatment in a SNF. She does not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, she does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.