Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and extraction (D7140) provided on November 16, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray and extraction. You say that you are low income and do not have that kind of money to pay the cost share for your dental visit. The Plan denied your request. The Plan says oral surgery procedures are not covered services of the dental plan. The Plan also says that the first intraoral periapical x-ray is 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. The only type of x-rays covered under your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and extraction (D7140) provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below knee protective cover.

You asked the Plan to pre-approve the requested item. You say that the cover is to protect the leg from damage. The Plan denied your request. The Plan says the cover is non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. The requested cover is not considered reasonable and necessary for the enrollee's prosthesis. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a below knee protective cover.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible laboratory work provided by a network facility on September 29, 2021.

You asked the Plan to waive the deductible the laboratory work. You say that you had a wellness visit and there should be no charges for the services. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 $300 deductible which applies to the laboratory work. 

The laboratory work you asked the Plan to waive the deductible falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to laboratory services.

This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on September 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible laboratory work provided by a network facility on September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health hospital stay provided from September 23, 2021, to September 30, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted against your will and should not be responsible for the copayment. 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 a $250 copayment for each inpatient mental health hospital stay per day for days 1-7. The contract also says that there is $0 copayment for days 8-90. The record shows you received the inpatient services. You have been asked to pay a total of $1,750 for an inpatient hospital stay ($250 copayment per day x 7 days = $1,750 copayment). Please note there is no cost sharing for the day of discharge. An inpatient mental health hospital stay falls 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 an inpatient mental health hospital stay provided from September 23, 2021, to September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on August 16, 2021. You asked the Plan to pay for the SelectMDx testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says there was no documented result of prior prostate biopsy. There was no documented significant interval increase in prostate-specific antigen level.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the SelectMDx testing (81479) provided on August 16, 2021. have not been met. Specifically, the documentation submitted does not include a lab report or medical records. We are unable to determine why this testing was ordered or how the results will affect the member's treatment. Additionally, per the Diagnostics exchange, this is not a covered test. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on August 16, 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 the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 you do not have documented skilled nursing needs or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 

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: 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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 you do not have documented skilled nursing needs or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 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 pay for an elbow orthosis provided to the enrollee on May 13, 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 the documentation submitted did not sufficiently support the billed supply code. 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 code L3761 is "Elbow orthosis (eo), with adjustable position
locking joint(s), prefabricated, off-the-shelf."
We asked our coder 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 services at issue in this case were not supported by the medical records. Our reviewer found the documentation includes a prescription for the requested items with diagnosis and length of need, however ordering physician documents "Radiculopathy affecting upper extremity" with no plan of treatment to support the durable medical equipment.
The diagnosis on the prescription and physician documentation are different.
We looked at this coder'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 an elbow orthosis provided to the enrollee on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting from October 8, 2021, to October 10, 2021.
You asked the Plan to reimburse you for the self-administered drugs. You say that you were admitted. You say that you were taken to a room and kept for a couple of days. You also say that all of the medications should be
covered under your hospital stay. The Plan denied your request. The Plan says the self-administered drugs were received in the emergency room and observation stay. The Plan says that these medications are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting from October 8, 2021, to October 10, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cold wrap (A9273), provided on July 28, 2021, through September 8, 2021.
You asked the Plan to pay for a cold wrap. You say that the item is medically necessary. The Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a cold wrap (A9273), provided on July 28, 2021, through September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a psychiatry video visit provided on November 3, 2021.
You asked the Plan to waive the copayment for a video visit. You say that you should not have a copayment. You also say that you have had video visits before with no copayment. 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 a $40 copayment for an outpatient mental health session. You have been asked to pay a $40 copayment for a video visit. A video visit with a psychiatrist falls within the Outpatient 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 a psychiatry video visit provided on November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 24, 2021, through February 25, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that information provided at the time of the appeal does not support medical necessity for inpatient hospitalization.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the record indicates that the enrollee was admitted for concern of alcohol withdrawal with possible Wernicke's encephalopathy in the setting of hypocalcemia and ketonuria. The record establishes that the admitting physician had a reasonable expectation of a length of stay spanning 2 or more midnights. The fact that the stay was shorter than two midnights does not negate this expectation. The elements of the coverage rule are satisfied. The requested service is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 24, 2021, through February 25, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiofrequency ablation of the genicular nerves (64624) provided on September 13, 2021.
You asked the Plan to pay for a radiofrequency ablation of the genicular nerves. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue is experimental/investigational.
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 a radiofrequency ablation of the genicular nerves.
Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the procedure at issue is considered to be an experimental/investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation of the genicular nerves have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of the genicular nerves (64624) provided on September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of the Vertiflex Superion device.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of the Vertiflex Superion device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pay for the admission. You say that this is needed to regain function. The Plan denied your request. The Plan says the services can be received in a different setting, for example, home with continued home health, in residential care, or home with close follow-up with the doctor.

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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on October 27, 2021.

You asked the Plan to pay for the services. You say that periodontal disease can make you lose your teeth if not addressed. The Plan denied your request. The Plan says the claim was denied payment in accordance with plan benefits, as the provider is out-of-network.

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 the services when the services are provided in-network. 

The rendering provider is not in the plan's network. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on October 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on October 15, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you knew you would be charged for any self-given drugs which is why you brought your own medications with you. You also say that you tried to save money by bringing your own medications with you, but they would not let you take them. The Plan denied your request. The Plan says self-administered drugs are not included in Part A or Part B coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on October 15, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.