Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management service provided on
October 22, 2019.
You asked the Plan to pay for the hospital discharge day management service. You say that the enrollee was
discharged to hospice care. You also say that at the time of the service, the Plan is responsible for the services.
The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all
Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management service provided on
October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0428) provided March 19, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived because you would have taken another means of transportation if you were able to. The Plan denied your request. The Plan says the copayment was correctly 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 $225 copayment for Ambulance Services. You have been asked to pay the Medicare allowed amount of $221.22 for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. In this case, the allowable amount was less than the $225 copayment listed in the Evidence of Coverage. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance transport (A0428) provided March 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora clinic visit and laboratory test provided on November 30, 2019.You asked the Plan to pay for clinic visit and lab test. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  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 clinic visit and lab test. Our reviewer says that these services meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could not have foreseen requiring these services prior to leaving the Plan's service area. These services were medically necessary. It would not have been reasonable to delay these services until the enrollee returned to the Plan's service area or until after December 31, 2019 when the enrollee disenrolled from the Plan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of clinic visit and lab test have been met.Therefore, we decided that the Plan has to pay fora clinic visit and laboratory test provided on November 30, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drug would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on
February 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the documentation submitted did not include a physician order/lab requisition or medical
records stating exactly what tests are to be performed.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22
or more drug class(es), including metabolite(s) if performed."
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 services. Our reviewers says that the
services at issue in this case were supported by the medical records. Our physician reviewer found the records
support the denied code. The results of lab testing described by the code are included in the records. The
records contain a valid physician order to support the denied code.
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 services have been met. Therefore, we decided that the Plan has to pay for
drug testing services (HCPCS G0483) provided to the enrollee on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Roho wheelchair cushion for use with a power operated vehicle (POV - a scooter).
You asked the Plan to pre-approve wheelchair cushion. You say that you are requesting this item. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this cushion would not fit your scooter and is not medically necessary for you.
The Plan must follow Medicare rules. Medicare rules say that a seating cushion is not covered for use with power operated vehicles. We looked at the file and Medicare rules. You are requesting this cushion for use with your scooter; however, Medicare does not cover this item for use with a power operated vehicle such as your scooter. Based on this information, we decided that Medicare rules for coverage of wheelchair cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a Roho wheelchair cushion for use with a power operated vehicle (POV - a scooter).
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the acute care hospital with acute respiratory failure due to pneumonia and acute kidney injury. The enrollee was intubated. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and periodontal maintenance provided on January 3, 2020.You asked the Plan to pay for the comprehensive periodontal evaluation and periodontal maintenance. You say that you weren't aware your dental wasn't covered when you changed plans.You say that you were informed you were covered. The Plan denied your request. The Plan says out-of-network dental services 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.Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation and periodontal maintenance provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on July 3, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 definitive drug testing rendered on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on January 14, 2020. You asked the Plan to pay for the crown. You say that dental services are included in your insurance coverage. The Plan denied your request. The Plan says this service is not covered. 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 crown provided on January 14, 2020.
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 you need aggressive rehabilitation. The Plan denied your request. The Plan says that your needs could possibly be met at a lower level care.
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. You do not require the intensity of services provided at an IRF. Specifically, 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a facility fee received on March 14, 2020.
You asked the Plan to pay for the fee. You say that you don't want to pay the facility fee assessment. The Plan denied your request. The Plan says there is an additional fee outside of the responsibility defined by the plan.
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 may have to pay an additional facility fee. You have been asked to pay an additional facility fee for the services received on March 14, 2020. 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 pay for a facility fee received on March 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you would like to appeal the Plan's denial because the services occurred on the same day the enrollee passed away. You say that the enrollee's care giver initially thought that the enrollee had just fallen as he had previously. You stated that the care giver called for anambulance not knowing that the enrollee was already deceased. You asked the Plan to reconsider providing coverage for the services.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 February 6, 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 forthe ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided to the enrollee from October 22, 2018 to October 25, 2018.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that this claim was filed untimely.
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 these services was not filed until May 8, 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 inpatient hospital services provided to the enrollee from October 22, 2018 to October 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for dressing supplies (A4452, A6196, A6402) provided February 5, 2020.
You asked the Plan to pay for the dressings. You say that the items were medically necessary and should be paid. The Plan denied your request. The Plan says payment for these items is included in payment for the SNF stay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes A4452, A6196, and A6402 are not supported in the medical record. Specifically, the place of service on the claim form indicates a covered SNF stay. In this case, payment for these items is included in the SNF payment and cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of the dressings have not been met. Therefore, we decided that the Plan does not have to pay for dressing supplies (A4452, A6196, A6402) provided February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the acupuncture services rendered from January 8, 2019 to December 16, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you have been inconsistently reimbursed. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture from an out-of-network provider with a 20% coinsurance. Review of the file shows that you received acupuncture from an out-of-network provider on January 8, 2019; October 21, 2019; and December 16, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the covered out-of-network acupuncture services benefit category. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. This means that you have been asked to pay the correct amount based on your contract with the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the acupuncture services rendered from January 8, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging provided on January 13, 2020.You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging. You say that you were told you would not be responsible for any payment. 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 $30 copayment for diagnostic procedures and tests at an in-network specialist's office. You have been asked to pay a $30 copayment for the ophthalmic diagnostic imaging. The ophthalmic diagnostic imaging 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 the ophthalmic diagnostic imaging provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and deductible for diagnostic tests and a copayment for an outpatient surgery provided by provider on August 23, 2019 to September 27, 2019.You asked the Plan to waive the copayment and deductible for diagnostic tests and an outpatient surgery. You say that you do not agree with these charges.The Plan denied your request. The Plan says the correct copayment and deductible 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 $1,000 deductible, a $40 copayment for outpatient diagnostic tests/in-network/diagnostic procedures, and a $350 copayment for an outpatient surgery/in-network. You have been asked to pay a $1,000 deductible, a $40 copayment for diagnostic tests, and a $350 copayment for an outpatient surgery. The total amount you are being asked to pay is $1,430 ($1,000 + $80 (2 visits) +$350 = $1,430). Diagnostic tests fall within the outpatient diagnostic tests/in-network/diagnostic procedures benefit. Outpatient surgery falls within the outpatient surgery/in-network 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 and deductible for diagnostic tests and an outpatient surgery provided by provider on August 23, 2019 to September 27, 2019.