Persius/hicric huggingface dataset:
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 enrollee is an extreme fall risk and need rehabilitation with a SNF. You state the enrollee cannot walk with assistance of walker, the enrollee is extremely weak and unsteady on their feet. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services the enrollee requires can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with their 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 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 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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services the enrollee requires can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is medically stable. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube that has been malfunctioning or is complex. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Care at a SNF for inpatient skilled rehabilitation services is not 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 1, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered screening test.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you need to finish your inpatient therapy at a SNF because you were doing great with therapy at the facility you were at in order to keep you from falling. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 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 SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0842) provided on July 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you were not aware you needed authorization. The Plan denied your request. The Plan says out-of-network services require authorization.  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 items/services at issue in this appeal. 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 drug testing (G0842) provided on July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (Kyphoplasty).  You asked the Plan to pre-approve Percutaneous Vertebral Augmentation (Kyphoplasty). You say that the requested Percutaneous Vertebral Augmentation (Kyphoplasty) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Percutaneous Vertebral Augmentation (Kyphoplasty).  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 Percutaneous Vertebral Augmentation (Kyphoplasty). Our reviewer says that the enrollee does not meet criteria for the requested Percutaneous Vertebral Augmentation (Kyphoplasty). Our physician reviewer found there is no documentation of imaging studies showing that the fracture is a recent fracture. Criteria have not been met. Also, recent literature show that Kyphoplasty is not more effective than conservative measures for compression fractures.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Percutaneous Vertebral Augmentation (Kyphoplasty) have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (Kyphoplasty).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the blood oxygen level measurement (94760) provided on April 27, 2021.  You asked the Plan to pay for the blood oxygen measurement. You say that you would like reconsideration because the services provided were medically necessary. The Plan denied your request. The Plan says certain procedures are commonly performed in conjunction with other procedures as a  component of the overall service provided.  The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance services does not include a separate payment for items and services furnished under the ambulance benefit.  We find that CPT code 94760 is not supported in the record. Specifically, separate payment is not made for this service. Payment for the blood oxygen testing is included in the fee schedule payment for the ambulance services. Based on this information, we decided that Medicare rules for coverage of the blood oxygen measurement have not been met. Therefore, we decided that the Plan does not have to pay for the blood oxygen level measurement (94760) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Extracorporeal Pulse Activation Technology (EPAT) treatment.  You asked the Plan to pre-approve EPAT treatment. You say that the requested Extracorporeal Pulse Activation Technology (EPAT) treatment is medically necessary. The Plan denied your request. The Plan says the requested Extracorporeal Pulse Activation Technology (EPAT) treatment is not medically necessary.  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 EPAT treatment. Our reviewer says that the requested Extracorporeal Pulse Activation Technology (EPAT) treatment is not medically necessary. Our physician reviewer found EPAT is experimental for foot pathology treatment. More research is needed. The requested EPAT treatment in this case is not 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 EPAT treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Extracorporeal Pulse Activation Technology (EPAT) treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the receiver and reprogramming provided on August 11, 2021.  You asked the Plan to pay for the receiver and reprogramming. You say that if this coverage is only good for new hearing aids then this is misleading. You say that this was for hearing aid technology and you should be reimbursed directly. The Plan denied your request. The Plan says the service is not covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan does not cover amplifiers, internet purchases, assistive listening devices (ALDs) or accessories.   We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the receiver and reprogramming have not been met. Therefore, we decided that the Plan does not have to pay for the receiver and reprogramming provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80307, G0480) provided on May 21, 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 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 lab services (80307, G0480) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the consultation (D9310) provided on June 14, 2021.  You asked the Plan to reimburse you for the dental service. You say that you were experiencing pain. You say that you were given antibiotics. You say that you had your tooth extracted. You say that they did not extract the entire tooth. You also say that you feel you should be reimbursed for this service. The Plan denied your request. The Plan says the consultation is not listed as a covered service.  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 consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the consultation (D9310) provided on June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 15, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you do not understand why you must pay for this service that you did not request. You say someone else called 911. 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 non-Medicare covered ambulance stabilization when there is no transport.  You have been asked to pay a $250 copayment for the ambulance services. The ambulance services fall within the Ambulance Services 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 ambulance services provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the additional intraoral x-rays (D0230 x 4), gingival irrigation (D4921 x 2), and the adjunctive pre-diagnostic test (D0431) provided from May 20, 2021, to May 25, 2021.  You asked the Plan to reimburse you for the dental services. You say that you had a lot of x-rays taken. You say that you were advised you needed a deep cleaning. You say that you feel that you did not receive a deep cleaning. You also say that you do not feel you should be responsible for these bills. The Plan denied your request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that gingival irrigation is not listed as a covered service. The Plan also says adjunctive pre-diagnostic test is not listed as a covered service either.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and intraoral x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 intraoral x-rays that you received on May 20, 2021. Additionally, the gingival irrigation and adjunctive pre-diagnostic test are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the additional intraoral x-rays (D0230 x 4), gingival irrigation (D4921 x 2), and the adjunctive pre-diagnostic test (D0431) provided from May 20, 2021, to May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.  You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary for the enrollee. This patient has had frequent hospital admissions for acute on chronic hypercarbic respiratory failure. There is a listed diagnosis of COPD, but no data to support it. The patient also has morbid obesity and obesity-hypoventilation syndrome.    The partial pressure of carbon dioxide (pCO2) was 60 on an arterial blood gases (ABG) done while the patient was acutely ill. This patient may benefit from nocturnal support with BiPAP. Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support that has been prescribed, and Medicare does not cover a ventilator when used as BiPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a pulmonologist on April 19, 2021.  You asked the Plan to waive the copayment for the pulmonology visit. You say that you weren't aware that you had a copayment.  You said that you had a previous telehealth visit and you didn't pay a copayment.  You stated that you were not aware that the copayment waiver program ended. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that the copayment waiver program was only in effect until December 31, 2020.  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 specialist visits (including telehealth).   You have been asked to pay a $40 copayment for the pulmonology visit. 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 telehealth visit you had with a pulmonologist on April 19, 2021.