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

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 30, 2021.
You asked the Plan to pay for the dental service. You say that you were advised by the dental office and a plan representative that the provider was in network. You also say that you feel this claim should be paid. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental service received out of network are not covered. The Plan also says that you did not contact them prior to the date of service to verify benefits and provider eligibility.
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, dental services you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 5, 2021 and January 26, 2021.
You asked the Plan to pay for the home visits. You say that the claim should be considered for payment as the services were necessary. The Plan denied your request. The Plan says prior authorization for out-of-network services was not obtained.
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 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 the home visit provided by an out-of-network provider on January 5, 2021 and January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 27, 2021, to March 30, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you feel you should be reimbursed. You also say that the hospital refused to let you use your own generic drugs. The Plan denied your request.
The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs
are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received 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 selfadministered
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 in an outpatient setting from March 27, 2021, to March 30, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee's needs are constant and requires assistance to function from day-to-day. The Plan denied your request. The Plan says SNF care 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The enrollee does not require skilled therapy services. The enrollee does not require services on an inpatient basis, only in a skilled nursing facility setting. Custodial care in a long-term care facility appears appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
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 you do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on June 11, 2021.
You asked the Plan to pay for full mouth debridement. You say that this service was necessary and should be covered. The Plan denied your request. The Plan says this service is not covered by your dental 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 the full mouth debridement (D4355) provided on June 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel coded R0070 provided on March 17, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel. 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. In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.
We find that CPT code R0070 is not supported in the medical record. Specifically, this code was billed with place of service 31 (skilled nursing facility). However, this code should have been billed with place of service 32 (nursing facility) since it was a non-covered stay Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel coded R0070 provided on March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on May 26, 2021.
You asked the Plan to waive the copayment for the MRI. You say that this copayment is too high and you cannot afford it. 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 $275 copayment for diagnostic imaging (including MRI). You have been asked to pay a $275 copayment for the MRI. The MRI falls within the diagnostic imaging benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on May 26, 2021.
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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 beneficiary is a 70-year-old male with myelopathy with cervical laminectomy and fusion and wound dehiscence of neck incision. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, you do 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 care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610) and triamcinolone acetonide 10MG injection (CPT code J3301) provided on April 20, 2021.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim did have the incorrect coinsurance amount as it was billed incorrectly. The Plan states that was corrected, lowering the coinsurance amount from $24.00 to $3.58. The Plan states both copayment and coinsurance are applicable.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received specialist services and an injection on April 20, 2021. You were asked to pay a $50 copayment for the specialist office visit. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $3.58. The total you owe is $177.48 ($17.88 x 20% = $3.58). Your total cost share responsibility is $53.58 ($50 + $3.58 = $53.58). Your 2021 EOC states enrollees must pay a $50 copayment for each specialist visit for Medicare-covered services and 0% coinsurance for all drugs covered under Original Medicare. 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 arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610) and triamcinolone acetonide 10MG injection (CPT code J3301) provided on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code 97116 X 6).
You asked the Plan to pre-approve additional physical therapy visits. You say that the treatment is medically necessary and greatly improves pain. You state it is important that you keep up with ultrasound therapy and electrical stimulation to treat plantar fasciitis. You state you are unable to stand or walk comfortably without this treatment. The Plan denied your request. The Plan says the services are not medically necessary because the notes do not show a change in functional abilities. The Plan states the notes do not show that the skills of a therapist are needed.
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 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 the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the Health Plan. You have had prior extensive therapy for her condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in and are compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code 97116 X 6).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (OT) services provided in the home on March 20, 2021, by an OT assistant (OTA).
You asked the Plan to pay for the OTA services. You say that the services are medically necessary. The Plan denied your request. The Plan says this is not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that OTA services can only be billed by the supervising therapist. Doctors and NPPs are not allowed to bill for these services as they do not meet the definition of the therapist.
These services are being billed by a nurse practitioner. As this NPP does not meet the definition of a therapist, the OTA services are not payable as billed. Therefore, we decided that the Plan does not have to pay for the occupational therapy (OT) services provided in the home on March 20, 2021, by an OT assistant (OTA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the outpatient mental health in-office visit provided on June 23, 2021.
You asked the Plan to waive the charges for the outpatient mental health visit. You say that you were not aware that if you went to see the provider in-person that you would have to pay. If you knew this, you would have done the free telehealth visit. The Plan denied your request. The Plan says while telehealth mental health visits have had the copayment waived, the Plan has not waived this cost sharing for in-person visits.
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 for in-person outpatient mental health visits. You have been asked to pay a $35 copayment for the outpatient mental health visit. The outpatient mental health visit falls within the in-person outpatient mental health visits benefit category. It is noted that telehealth psychotherapy generally has a $30 copayment, but the Plan has chosen to waive this. There is nothing in the
file showing that you were informed the in-person copayment has been waived. 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 charges for the outpatient mental health in-office visit provided on June 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) evaluation provided in the home on January 20, 2021.
You asked the Plan to pay for the PT evaluation. You say that this should be payable. The Plan denied your request. The Plan says this is not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that physical therapy services being billed by a physician or NPP must be provided under direct supervision of the billing provider. In this case, the services were rendered by a physical therapist in the patient's home but are being billed by a physician assistant. Since the physician assistant was not present in the home to provide direct supervision, payment to this provider for the services rendered is not allowed. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) evaluation provided in the home on January 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 14, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that you are not able to walk because your provider said no walking as of right now. The Plan denied your request. The Plan says the stay 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no documented skilled nursing needs. Based on review of the records, you did not meet the Centers for Medicare & Medicaid Services (CMS) coverage criteria for a stay in the SNF after September 30, 2021. Your stay in the SNF was not reasonable and not medically necessary for you, who has a left foot ulcer. You did not need any nursing care other than routine care. Completed your intravenous (IV) antibiotics. You had no skilled nursing needs. Functionally doing well. Documentation does not support the need for a stay in SNF with daily skilled therapies in an inpatient setting. Your care needs could have been safely provided at an alternate and lower intensity setting such as in a long-term care (LTC) facility with intermittent therapies or in home with 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from October 14, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the documentation does not support the need for SNF care. The Plan says that the enrollee can safely receive the services needed in the long-term acute care hospital.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition and enteral and inhaled medications and insulin. The enrollee had stable vital signs, remained ventilator and dialysis dependent, and was treated for a stage 4 right heel ulcer. There are no therapy notes to document skilled therapy. There are identifiable skilled nursing service needs, but they are not required on a daily basis. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit and x-ray imaging provided on April 21, 2021.
You asked the Plan to pay for the office visit and imaging. You say that these services were needed so the provider could make a diagnosis and treat you. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Although these service may be appropriate, they are not covered by Medicare or your health plan. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit and x-ray imaging provided on April 21, 2021