Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health aide and 4 home health skilled nursing visits.
You asked the Plan to pre-approve 7 home health aide and 4 home health skilled nursing visits. 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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
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 7 home health aide and 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation to support the need for skilled nursing services. There is no documentation that the enrollee is in need of any specific therapies for a specific condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health aide and 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health aide and 4 home health skilled nursing visits.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted for congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the colonoscopy and services provided by a gastroenterologist on May 14, 2021.
You asked the Plan to waive the copayments for the colonoscopy and gastroenterology services. You say that you had a screening colonoscopy so no copayment should be due. 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 $75 copayment for outpatient surgery at an ambulatory surgery center and a $20 copayment for surgical services provided by a specialist. You have been asked to pay a $75 copayment for the colonoscopy and a $20 copayment for the gastroenterology services. According to your medical records, during the course of your colonoscopy, two polyps were found and removed. Your contract with the Plan explicitly states that if any abnormality is found during a screening colonoscopy, it will cease to be considered 'screening' and the outpatient surgery copayment will apply. That is why you were charged the $75 copayment for outpatient surgery. Your contract also says that you may also be charged a separate copayment for the surgical services provided by the doctor. 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 colonoscopy and services provided by a gastroenterologist on May 14, 2021.
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 you are in a lot of pain and your husband is unable to help you. The Plan denied your request. The Plan says the requirements for approval of 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy and occupational therapy while in the acute hospital. The enrollee was at a supervision/set-up level with functional mobility, including gait to 180 feet with a rolling walker. The enrollee required varying assist with activities of daily living. the enrollee could negotiate stairs with supervision/setup assist. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy services, but they are not required on a daily basis. 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: 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 there is no evidence that you require services that are not currently available at the present setting where you are receiving care. You can remain at the current setting until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on March 5, 2021.
You asked the Plan to pay for the ambulance service. You say that you do not understand why you are to pay
for a fire department visit to your emergency. You say that you do not have control over who shows up to an
emergency. You also say that you thought this would be covered. The Plan denied your request. The Plan says
the Medicare ambulance benefit is a transportation benefit. The Plan also says that without a transport there is
no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on March 5, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on March 5, 2021.
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 you are not able to manage your trach and could suffocate. You say that it is not safe to return home. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can safely receive the services needed in the current hospital setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral and medications. The enrollee had stable vital signs and was treated for pain. The enrollee had a tracheostomy. The enrollee received physical therapy and was independent with transfers. The enrollee could walk 150 feet. There are no identifiable skilled therapy service needs. While there are identifiable skilled nursing service needs, they are not required on a daily basis. 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: 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 is not medically
necessary.
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 based on the documentation provided you do not require the intensity of services
provided at an IRF. Specifically, the you are not shown to require fifteen hours per week of rehabilitative
services and regular physician evaluation. Your care needs can be met 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 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 an additional amount for a bitewing radiographic image (D0270), intraoral periapical radiographic images (D0220 x2, D0230), a limited oral evaluation (D0140), endodontic therapy (D3330), a prefabricated post and core (D2954), and a crown (D2740) provided from January 19, 2021, through February 25, 2021.
You asked the Plan to pay an additional amount for a bitewing radiographic image, intraoral periapical radiographic images, a limited oral evaluation, endodontic therapy, a prefabricated post and core, and a crown. You say that you think the provider has billed you incorrectly. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made. A prefabricated
post and core, and a crown are not covered benefits.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a bitewing radiographic images, intraoral periapical radiographic images, a limited oral evaluation, endodontic therapy, a prefabricated post and core, and a crown have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Additionally, a prefabricated post and core, and a crown are not covered benefits. Therefore, we decided that the Plan does not have to pay an additional amount for a bitewing radiographic image (D0270), intraoral periapical radiographic images (D0220 x2, D0230), a limited oral evaluation (D0140), endodontic therapy (D3330), a prefabricated post and core (D2954), and a crown (D2740) provided from January 19, 2021, through February 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 19, 2021, to April 17, 2021.
You asked the Plan to pay for the SNF care. You say that the SNF care provided was medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for SNF care coverage had 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 66-year-old male with chronic respiratory failure, chronic obstructive pulmonary disease, diabetes, depression and hepatitis C with hospitalization for acute on chronic respiratory failure. In this case, there were no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary did not require any skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary did not meet the severity of illness or intensity of service criteria for SNF 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 19, 2021, to April 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from October 8, 2018, to October 9, 2018.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted to the hospital and the emergency copayment does not apply. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were admitted to outpatient observation. 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 emergency room visit provided from October 8, 2018, to October 9, 2018.
Your complaint about receiving the bill three years later 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of a peri-implant defect (D6101) provided on May 19, 2021.

You asked the Plan to pay for the debridement of a peri-implant defect (D6101). You say that you had a problem with your gums and had to get a procedure for your health. You say that you are on low income and cannot pay for this. The Plan denied your request. The Plan says the service 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. Therefore, we decided that the Plan does not have to pay for the debridement of a peri-implant defect (D6101) provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 29826 is not supported.
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 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). We find that CPT code 29826 is not supported in the medical record. Specifically, there is no documentation of a surgical shoulder arthroscopy with decompression of subacromial space with a partial acromioplasty. 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 pay for the surgical services rendered on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services (G2066) provided on March 27, 2021.
You asked the Plan to pay for the cardiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 cardiology services (G2066) provided on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (G0283) provided May 10, 2021 to May 14, 2021.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered under Medicare rules.
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. Therefore, we decided that the Plan does not have to pay for chiropractic services (G0283) provided May 10, 2021 to May 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.
You asked the Plan to pre-approve Reblozyl. 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. 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 Reblozyl. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that that the enrollee has myelodysplastic syndrome and is receiving at least weekly blood transfusions. The record indicates that the enrollee has anemia with sideroblasts. The elements of the coverage criteria are not satisfied. The requested service is not 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.