Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from February 12, 2021, to February 14, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you only stayed at the hospital for one day. You say that you should be liable for only one copay of $360. 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). Your contract with the Plan clearly says that you must pay $360 per day for days 1-5 and $0 per day after day 5 for in-network inpatient hospital care.
The record shows you were in the hospital from February 12, 2021, to February 14, 2021, but there is no copayment for the date of discharge. Therefore, you have been asked to pay $360 per day for the first two days of inpatient hospital services. The total for your stay is $720. Inpatient hospital services fall 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 services provided from February 12, 2021, to February 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the inpatient hospital stay you received on May 6, 2021, and the outpatient surgeries you had on May 7, 2021, May 20, 2021, and June 18, 2021.  You asked the Plan to waive the copayments for the inpatient hospital stay and the three outpatient surgeries. You say that you shouldn't have to pay multiple copayments because they were not able to complete the procedure the first time. 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 $295 copayment per admission for inpatient hospital services and a $225 copayment for each outpatient surgery.   You have been asked to pay a $295 copayment for the inpatient hospital stay and a $225 copayment for each of the three outpatient surgeries. 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 inpatient hospital stay you received on May 6, 2021, and the outpatient surgeries you had on May 7, 2021, May 20, 2021, and June 18, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve docetaxel and gemcitabine HCl.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has sacroma and was previously treated with gemzar and taxotere with response. As she did not fail this regimen and it meets the National Comprehensive Cancer Network (NCCN) compendia, the requested services are reasonable and medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve docetaxel and gemcitabine HCl.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve continued inpatient mental health services.  You asked the Plan to pre-approve continued inpatient mental health services. You say that the services are medically necessary. The Plan denied your request. The Plan says that coverage criteria is no longer met.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 continued inpatient mental health services. Our reviewer says that continued inpatient treatment is medically necessary. Our physician reviewer found although the enrollee did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations, she did have psychosis, delusions, and irritability. It is medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the denial date.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health services have not been met. Therefore, we decided that the Plan has to pre-approve continued inpatient mental health services.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete upper and lower denture provided on August 5, 2021.  You asked the Plan to pay for the complete upper and lower denture. You say that it had been several years since you had dentures, so you made this appointment to see about getting dentures. You say that you have been without dentures for several years and the Plan should pay. The Plan denied your request. The Plan says only one complete upper and lower denture is covered every five 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.     Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one complete upper and lower denture every five years. The Plan paid for the complete upper and lower denture provided on April 18, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete upper and lower denture provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on May 19, 2021.  You asked the Plan to pay for the GeneSight Psychotropic test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.    We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation does not support that the claim was submitted with the required Z code identifier. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic test have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (29828, 29823) provided May 25, 2021.  You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the codes billed.  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, the CPT Code Manual definition of codes 29828 and 29823 are Surgical shoulder arthroscopic biceps tenodesis and Surgical shoulder arthroscopy with extensive debridement.  We find that CPT codes 29828 and 29823 are not supported in the medical record. Specifically, the operative report does not include documentation of arthroscopic biceps tenodesis. Furthermore, there is not documentation of extensive debridement. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (29828, 29823) provided May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from July 29, 2020, through August 5, 2020 with the reported principal diagnosis A41.51, sepsis due to escherichia coli [E. coli].  You asked the Plan to pay for inpatient services provided from July 29, 2020, through August 5, 2020 with the reported principal diagnosis A41.51, sepsis due to escherichia coli [E. coli]. The Plan denied your request. The Plan says according to coding guidelines and the documentation in the medical record these conditions did not qualify for reporting.  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 the principal diagnosis A41.51, sepsis due to escherichia coli [E. coli]. 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 inpatient services provided with the reported principal diagnosis A41.51, sepsis due to escherichia coli [E. coli]. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation supported an admission for pyelonephritis. The documentation was inconsistent regarding a diagnosis of sepsis. The enrollee was a then a 79-year-old male with a past medical history of cerebrovascular accident (CVA) and chronic kidney disease (CKD) stage 3. He presented to the emergency department (ED) with cough, shortness of breath, fever, and weakness. While the enrollee's presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. The Glasgow Coma Scale (GCS) was between  14-15 throughout admission; with GCS of 14 ED notes state "Is the patient's mental status different from baseline? No" Platelets were 231-309. Bilirubin was 0.4-0.7mg/dL. Patient with history of CKD presented to the ED with creatinine of 1.82mg/dL and was 2.09mg/dL at discharge. The mean arterial pressure (MAP) remained > 70. The review has determined that the principal diagnosis A41.51, sepsis due to escherichia coli [E. coli], was not supported by the medical records.  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 inpatient services provided from July 29, 2020, through August 5, 2020 with the reported principal diagnosis A41.51, sepsis due to escherichia coli [E. coli].
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to waive the cost sharing for the electrocardiogram (ECG) you had at an outpatient hospital facility on June 17, 2021.  You asked the Plan to waive the cost sharing for the ECG. You say that you already paid a $10 copayment on this date, so you shouldn't have additional cost sharing. The Plan denied your request. The Plan says that because the ECG is a basic imaging service, the deductible applies.  You had not yet met your deductible at the time of this service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies to certain services.  The deductible does apply to imaging services, but it does not apply to diagnostic tests. The contract also says that enrollees pay a $10 copayment for diagnostic tests, per day, per facility.  The Plan says you must pay $8.81 towards your deductible for the ECG. However, this is not correct. First, an ECG is not an imaging service- it is a diagnostic test. So, the Plan incorrectly categorized this service, causing the deductible to apply. The deductible does not apply to diagnostic tests. Second, although the deductible does not apply to the ECG, there is a $10 copayment for diagnostic tests. However, according to your appeal, you already paid a $10 copayment for services rendered by the facility on this same date. The Plan has not disputed this. Your contract states that the $10 obligation is a per-facility/per-day copayment. Since you already paid a $10 copayment on that date, it would not be appropriate for the Plan to assess additional cost sharing for the ECG. Therefore, we decided that the Plan has to waive the cost sharing for the electrocardiogram (ECG) you had at an outpatient hospital facility on June 17, 2021.        If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in home with intermittent therapies.  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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health care services provided from June 14, 2021, through July 11, 2021.  You asked the Plan to pay for home health care services. 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. 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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health care services provided from June 14, 2021, through July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0482) provided on July 2, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network lab services were not authorized.  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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an osseous surgery (D4261) provided by an out-of-network provider on July 29, 2021.  You asked the Plan to pay for an osseous surgery. You say that you would like the Plan to pay for these charges. The Plan denied your request. The Plan says the dental services provided are not a covered benefit.  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 an osseous surgery provided by an out-of-network provider on July 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 13 to July 27, 2021.  You asked the Plan to pay for psychotherapy services. You say that previous claims for visits to the same doctor have been reimbursed. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 13 to July 27, 2021.   Your complaint about the Plan covering previous visits for psychotherapy services 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: 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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met at a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided by a participating provider on July 20, 2021.  You asked the Plan to pay for comprehensive oral evaluation. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says this dental benefit has already been exhausted.  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 one comprehensive oral evaluation procedure to be provided every three years.  We looked at the file and Medicare rules. Evidence was provided that shows a comprehensive oral evaluation was provided on May 25, 2021. Based on this information, we decided that the Plan's rules for coverage of comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided by a participating provider on July 20, 2021.