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

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until October 6, 2020. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for the services provided on April 10, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan does not have to waive the cost share charged for outpatient lab services and
outpatient surgery provided on April 7, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided. Maximus
partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that it has been determined that these services were originally billed under a claim processed on
April 13, 2020. The Plan states that the provider submitted a corrected claim on April 21, 2020 and it was
processed under the appealed claim. The Plan states it did not include the original claim Explanation of
Benefits that shows the coinsurance for the laboratory services, which was included with the reopen review.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Plans must provide
clear contract information. The Plan contract clearly states there is a cost share for outpatient lab services and
outpatient surgical services. Based on review of the new information submitted by the Plan, 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 cost share charged for outpatient lab services and outpatient surgery provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (82570, 84300, 84150) provided September 23, 2020 to September 28, 2020.
You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 $10 copayment for lab services. You have been asked to pay a $18.63 copayment for 4 lab services. This is less than the $10 per-service copayment listed in the plan contract. 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 lab services (82570, 84300, 84150) provided September 23, 2020 to September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional fifteen (15) Logisticare miles.
You asked the Plan to pre-approve additional miles. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the member's benefit only allows 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. You are requesting an additional 15 miles for a total of sixty-five (65) miles. The member's benefit only allows 50 miles. The member has exceeded their benefit limit. This request is not covered by the member's health plan. The health plan contract says each one-way trip must not exceed fifty (50) miles of driving distance. Therefore, we decided that the Plan does not have to pre-approve additional fifteen (15) Logisticare miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walker provided by a participating
provider on August 21, 2020.
You asked the Plan to waive the coinsurance for a walker. You say that you were told that this would be free.
The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20%
coinsurance for durable medical equipment.
You have been asked to pay a 20% coinsurance of the allowed amount for a walker. The total allowed amount
is $85.69. The total amount you are being asked to pay is $17.13 ($85.69 x 20% = $17.13). A walker falls
within the durable medical equipment 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 coinsurance for a
walker provided by a participating provider on August 21, 2020.
We note your complaint about being told that this would be free. Your complaint is a grievance that must be
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.

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 there is no documentation provided necessitating admission to a LTACH. The
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee
requires that are not available at the health care setting being offered by the health plan. The requested LTACH
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee
and able to be furnished safely and effectively only on an inpatient basis.

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 admission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0425, A0427)
provided on July 26, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you believe that the
copayment as charged is too high. The Plan denied your request. The Plan says the copayment has processed
correctly for this case.

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 ambulance services.

You have been asked to pay a $250 copayment for the ambulance services. The services provided 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 (A0425, A0427) provided on July 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July
10, 2020, to July 17, 2020.

You asked the Plan to pay for SNF services provided from July 10, 2020, to July 17, 2020. You say that the
services which the enrollee required and received on the dates of service are coverable under the Medicare Act.
The Plan denied your request. The Plan says no skilled nursing or therapy services were provided.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 SNF services provided from July 10, 2020,
to July 17, 2020. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The
enrollee did not require daily skilled nursing and/or skilled therapy on 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 SNF services provided from July 10, 2020, to July 17, 2020 have not been met.
Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services
provided from July 10, 2020, to July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to get stronger. The Plan
denied your request. The Plan says the records do not support the ability to tolerate an intensive rehab therapy
program.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

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 physician reviewer found
that the enrollee was admitted to the acute hospital for diabetic ketoacidosis, COVID-19 infection, respiratory
failure and acute tubular necrosis. His medical conditions are stable. The complexity of his nursing, medical
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. There is not a reasonable expectation that he will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehab program.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke with right sided hemiparesis. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on July 31, 2020, to August 21, 2020.

You asked the Plan to waive the copayment for pain management services. You say that these services never took place. The Plan denied your request. The Plan says the correct copayments have been applied.

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 physician/practitioner services/specialist visits.

 You have been asked to pay a $50 copayment for pain management services. The total amount you are being asked to pay is $100 ($50 x 2 visits = $100). Evidence was provided to show that the correct copayment has been applied to the services that were provided. Pain management services fall within the physician/practitioner services/specialist visits 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 specialist office visit provided by a participating provider on July 31, 2020, to August 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 9, 2020.

You asked the Plan to pay for the ambulance services. You say that the medics wanted to transport you a hospital that was too far from your home. The Plan denied your request. The Plan says these services are not a covered benefit.

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 September 9, 2020. 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 services provided on September 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete ultrasound examination of the
abdomen (76700) provided October 27, 2020.

You asked the Plan to waive the copayment for the abdominal ultrasound. You say that due to COVID the free
standing clinics only does mammograms while all other tests are sent to the hospital. COVID has added many
restrictions. Please adjust the copay for free standing amount. The Plan denied your request. The Plan says this
claim processed and the correct copayment was applied per the Evidence of Coverage.

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 $100
copay for services in an outpatient hospital facility.

You have been asked to pay $100 copay for the abdominal ultrasound. The abdominal ultrasound falls within
the Outpatient diagnostic tests and therapeutic services and supplies 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 complete ultrasound examination of the abdomen (76700) provided October 27,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TTFT (CPT Code E0766).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says TTFT is not covered for mesothelioma. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. TTFT is not covered for mesothelioma. The rules say that Tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM). Therefore, we decided that the Plan does not have to pre-approve TTFT (CPT Code E0766).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botulinum Toxin A injection (J0585)
provided on May 30, 2019.

You asked the Plan to waive the coinsurance for the Botulinum Toxin A injection. You say that you were not
aware of the charges prior to the service. The Plan denied your request. The Plan says the coinsurance has
processed correctly in this case.

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 $20%
coinsurance for Medicare Part B drugs.

You have been asked to pay a total cost share of $142 for Botulinum Toxin A injection ($710 allowed amount
x 20% coinsurance). The service provided falls within the Medicare Part B drugs 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 coinsurance for the Botulinum Toxin A injection (J0585) provided on May 30,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.

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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy. There is no instability.
Hardware not needed.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.