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

We decided that the Plan does not have to waive the copayment for ambulance services you received on July 12, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the ride was very short, so you don't think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this 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 $200 copayment per trip for ambulance services. You have been asked to pay a $200 copayment per trip for the ambulance services. This copayment applies regardless of how long the trip is. 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 ambulance services you received on July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) service you received on April 1, 2021.

You asked the Plan to waive the copayment for the PT service. You say that this service should be covered because it was medically necessary. The Plan denied your request. The Plan says it did not deny this PT service. Rather, you were assessed a copayment. The Plan says that you were charged this 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 $35 copayment per visit for physical therapy services. 

You have been asked to pay a $35 copayment per visit for the PT service. 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 physical therapy (PT) service you received on April 1, 2021.
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 you are appealing with supporting records. 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) car
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 12, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were in pain and in need of an oral evaluation. You received medication for an infection to minimize pain and discomfort. You also say you are disabled; you do not work and cannot afford to pay this amount. The Plan denied your request. The Plan says comprehensive oral evaluation exams are covered once every three years.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation once every three plan years. We looked the file and Medicare rules. The records show that you received a limited oral evaluation on March 18, 2020, therefore, you have exhausted your maximum benefit for this service Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met.
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 19, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says there is no documentation of a face to face evaluation.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee resides in Maine; however, the "Certificate of Medical Consultation" was completed by an MD documented to be in Kansas and Texas. There was no documentation of a face-to-face evaluation completed. There was no specific clinical rationale for the requested laboratory testing. The review has determined that the enrollee did not meet the criteria for this testing. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services billed with DRG 871 provided September 4, 2020 to September 10, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.9 (Sepsis, unspecified organism) and secondary diagnosis code assignment of R65.20 (Severe Sepsis Without Septic Shock), G93.41 (Metabolic Encephalopathy), E87.2 (Acidosis), and N39.0 (Urinary Tract Infection, site not specified). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the documentation supported an admission for Pyogenic arthritis, unspecified. The documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though severe sepsis was documented on history and physical examination, progress notes and discharge summary, supporting medical record documentation was not found within the record. The enrollee was found by family wandering nude and confused. Appeal letter notes leukocytosis and vital signs were initially normal but later spiked a fever. Though white blood cell count was 15.4, Neutrophil was 13.4 and lactate 2.4 are noted upon presentation, these values promptly improved with treatment in the emergency department. The documentation noted that the enrollee was alert and oriented to person, place, and year, not oriented to situation or date. The enrollee was given antibiotic. The enrollee has a history of dementia and had a recent admission for acute ischemic stroke. Computed tomography (CT) of Head revealed no acute abnormality. Infectious Disease consultation noted that the enrollee was found septic due to fever 101.7, white blood cell count of 15.4 and lactic acid 2.54. Blood and fluid cultures were negative. Altered mental status improved, no fever, and leukocytosis improved. There was no documented hypotension and creatinine as platelets and total bilirubin values were within normal limits. There was no clinical evidence of sepsis. The review has determined that the DRG billed was not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services billed with DRG 871 provided September 4, 2020 to September 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from June 10, 2021,
through June 11, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says continuation of SNF
services 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 pay for SNF services. Our reviewer says that daily
skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the
enrollee received oral medications. The enrollee had stable vital signs. He was treated for pain. Regarding
rehabilitation services, the enrollee received physical therapy (PT) in the SNF. By the dates in question, the
enrollee was refusing therapy. 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. As a practical matter, 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pay for continuation of SNF services provided from June 10, 2021, through June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine and an MRI of the thoracic spine.
You asked the Plan to pre-approve an MRI of the cervical spine and an MRI of the thoracic spine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the cervical spine and an MRI of the thoracic spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical necessity of the ordered MRI scans has not been established. In this enrollee with upper midline back pain at the minimum plain films of the thoracic spine would be necessary. No explanation is offered by the ordering physician for MRI of the cervical spine except for the statement: "to complete the evaluation."
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the cervical spine and an MRI of the thoracic spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine and an MRI of the thoracic spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on July 9, 2021.
You asked the Plan to pay for the dental service. You say that you went in for a cleaning. You say there is nothing wrong with your teeth. You say that there was no need for an x-ray. You say that your insurance did not tell you that if you let them do the x-ray that you would have to pay. You also say you feel you should not be responsible for this bill. The Plan denied your request. The Plan says 1 complete series x-ray is covered every 3 plan years. 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 complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on June 10, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on July 9, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits (97164).
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the additional physical therapy should be covered. The Plan denied your request. The Plan says that the documentation does not support coverage for additional 10 physical therapy visits and 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 10 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 that the number of visits is excessive for this condition as it is unlikely that the enrollee will improve any further with therapy for a chronic condition. The enrollee does not need a skilled therapist. There is no documentation showing that the physical therapy services are part of a maintenance program. There is no clinical evidence to support the medical necessity of the additional physical therapy or that the enrollee meets the Medicare criteria for continued physical therapy 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 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits (97164).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from December 1, 2020, through December 3, 2020, billed with a secondary diagnosis code E87.2.
You asked the Plan to pay for the inpatient care as billed. You say that the inpatient care as billed is supported by the medical documentation. The Plan denied your request. The Plan says the secondary diagnosis is not supported in the medical documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code, E87.2, defined as acidosis. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient care as billed. Our reviewer says that the inpatient care as billed is not supported by the medical records provided. Our physician reviewer found that the reviewed documentation indicates that the serum lactic acid in the emergency department on December 1, 2021 was 2.7. The enrollee was evaluated and admitted with a diagnosis of chronic obstructive pulmonary disease exacerbation. The level decreased to 1.7 with intravenous fluids. There was no documentation of lactic acidosis. The review has determined that the documentation did not support the billed secondary diagnosis code E87.2 defined as acidosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from December 1, 2020, through December 3, 2020, billed with a secondary diagnosis code E87.2.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 3, 2021.
You asked the Plan to pay for the services provided. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival. The Plan denied your request. The Plan says they are unable to confirm the requirement of the genetic testing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that respiratory and coronavirus panel testing was provided. We find that the testing at issue is not supported in the medical record. Specifically, the records provided do not show that the testing was ordered, and the results would be used, in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 22, 2021.
You asked the Plan to pay for ambulance services. You say that the patient was in the care of hospice beginning January 29, 2021 and ending February 6, 2021. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 6, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 22, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 29, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this test is 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient reliable evidence in the form of high quality peer-reviewed medical literature to establish the efficacy or effects on health care outcomes for this testing. The review has determined that the enrollee does not meet the criteria for this request. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided from May 4, 2021, through May 5, 2021.
You asked the Plan to pay for non-emergency transportation, wheelchair van. You say that there was no other way to get back home to New York State for hospital care. The Plan denied your request. The Plan says wheelchair van, stretcher van and ambulette transportation are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) provided by from May 4, 2021, through May 5, 2021.