Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 7,
2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you woke up during the procedure
and it was very traumatic and you should not owe a copayment for this reason. 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 $300
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy 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 copayment for a colonoscopy provided on December 7, 2020.
We note your complaint that you woke up during the procedure. Your complaint is a grievance that must be
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with history of pulmonary embolism, hypothyroidism and hypertension. From a nursing perspective, there are no notes to substantiate further skilled needs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision to contact guard assist level with functional mobility including gait to 350 feet with a single point cane. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve the IRF care. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that physical therapy has the equipment you need to improve and maintain your balance. The Plan denied your request. The Plan says additional visits are 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 12 additional physical therapy 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 records provided, you appear to have made very little objective improvement with therapy. Further skilled therapy beyond the approved visits does not appear to be likely to achieve any significant improvement in your symptoms or functional status. The provided records do not clarify why the approved additional visits are inadequate to treat your 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 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from a critical illness recovery hospital to allow for more time to maximize recovery and allow for a stable discharge. You also say that the enrollee exceeds the criteria for an LTACH appropriate admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require a transfer to a 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. Our physician reviewer found in this case the enrollee was admitted with congestive heart failure exacerbation and acute on chronic hypercapnic respiratory failure with cor pulmonale requiring intubation. The enrollee is improving and is not on the ventilator and has no complex wound care or intravenous medication needs. Our reviewer found that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. Our physician reviewer also found that the requested LTACH services cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that the clinical information provided supports the need for SNF care. The Plan denied your request. The Plan says the information does not support that daily skilled services can only be provided on an inpatient basis in a SNF. The Plan says that the enrollee can safely receive the services needed in the current hospital setting.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with chronic lung disease requiring oxygen who was admitted on 9/4/2021 after a fall resulting in a left hip fracture with right toe fractures. The most recent therapy documentation indicates the member requires moderate to maximal assistance with mobility and continued assistance with self-care tasks. The member has stabilized medically and is ready for discharge from the hospital. 

The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a preventive medicine visit provided on November 20, 2020.

You asked the Plan to pay for preventive medicine visit. You say that you are appealing this denial of payment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered, and the provider is out-of-network with the Plan.

The Plan must follow Medicare rules. Medicare rules say that routine physical examinations are not covered by Medicare. 

We looked at the file and Medicare rules. This service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of preventive medicine visit have not been met. Therefore, we decided that the Plan does not have to pay for a preventive medicine visit provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dental services provided on January 7, 2021.

You asked the Plan to waive the coinsurance for exam (D0120) and cleaning (D1110). You say that the enrollment guidebook shows the preventative dental benefit is $0 copayment. The Plan denied your request. The Plan says the enrollee used an out-of-network provider therefore the share of the costs for the covered services is higher.

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 if they choose to see an out-of-network dentist they might be billed for charges above what the Plan pays, even for services listed as $0 copayment, for Covered Dental Procedures.

The enrollee has been asked to pay $89 for the out-of-network services. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the dental services provided on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the
requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. You say that you are out of state on an emergency
and your shoulder is hurting. The Plan denied your request. The Plan says your insurance only covers in-network
providers to get medical care and services. The only exceptions are emergencies, urgently needed
services or when the services in network are not available.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical
therapy services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on February 8, 2021.

You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that the requested items are a medical necessity for the enrollee for prevention of deep venous thrombosis or pulmonary embolisms. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis or pulmonary embolisms.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 27, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you can pay half to get the crown lengthening, but you cannot pay the full amount. You also say that you would like insurance to cover some of this. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that the patient requires transportation to the cancer treatment facility for medically necessary care. The Plan denied your request. The Plan says the benefit covers up to 50 one-way trips ever year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at your request, the records in the case file, and the rules. The file shows that the routine transportation benefit only covers up to 50 one-way trips every year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that the requested provider treated you in 2017 and you are requesting reconsideration for an office visit consultation with this provider. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 physician services provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the repair of a prosthetic device provided from February 25, 2021, to April 13, 2021.

You asked the Plan to waive the coinsurance for the repair of a prosthetic device. You say that you do not owe these 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 20% coinsurance for prosthetic devices and related supplies. 

You received the repair of a prosthetic device provided from February 25, 2021, to April 13, 2021, for a total of 4 services. The total allowed amount per each service is $39.20 and 20% of that is $7.84. The total amount you
owe is: $7.84 (coinsurance) x 4 (services) = $31.36. 

You have been asked to pay the total coinsurance amount of $31.36 for the repair of a prosthetic device. The repair of a prosthetic device falls within the prosthetic devices 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 the repair of a prosthetic device provided from February 25, 2021, to April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on March 30, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the enrollee called the Plan and was told this service would be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that the enrollee did not contact the Plan regarding dental coverage.

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 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on March 30, 2021.