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

We decided that the Plan does not have to pay for the BLS ambulance service (A0428) and mileage (A0425)BLS routine disposable supplies (A0382) Ambulance waiting time, 1/2) hour increments (A0420) and ambulance oxygen and oxygen supplies (A0422) provided September 12, 2019.You asked the Plan to pay for the BLS ambulance service (A0428) and mileage (A0425)the. You say that please reconsider the denial and approve the services so that you could pay the plan's copay instead of the total amount being billed.The Plan denied your request. The Plan says these items are not separately payable by Medicare and is included in the payment of the ambulance service.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 $265 copayment for each ambulance trip. The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separatelypayable.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the have not been met. Therefore, we decided that the Plan does not have to pay for the BLS ambulance service (A0428) and mileage (A0425)BLS routine disposable supplies (A0382) Ambulance waiting time, 1/2) hour increments (A0420) and ambulance oxygen and oxygen supplies (A0422) provided September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe study provided to the enrollee on October 2, 2019.You asked the Plan to pay forthe study. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the duplex scan, was requested solely for screening purposes. Medicaredoes not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe study provided to the enrollee on October 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not haveto pay for the medical services to be provided by an out of network (OON) provider.You asked the Plan to pay for the home health services (S9123) provided on August 8, 2018 through August 13, 2018. You say that you would like reimbursement for home health services because you did not have a medical assistant at home. The Plan denied your request. The Plan says there was no prior authorization for the non-urgent services.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 care that cannot be provided by network providers.The requested provider in this case isnot a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for these items/services. Additionally, these services require prior authorization from the Plan. Therefore, we decided that the Plan does not have to pay for the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on September 25, 2019.You asked the Plan to waive the copayment forthe MRI. You say that the MRI was done in the same hospital you see your primary care physician. You say that you were informed there would be no out-of-pocket cost.The Plan denied your request. The Plan says the copayment applied 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 $200 copayment for CT scans performed by an in-network provider other than your primary care physician.You have been asked to pay a $200 copayment for the MRI. The MRI 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 forthe MRI provided on September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.ThePlan 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 todetermine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted on 03/14/2020 after falling. He sustained a closed comminuted intertrochanteric left femur fracture. He underwent surgery the next day with intramedullary rodding. He is weight bearing as tolerated. His relevant past medical history includes Type II diabetes, stroke in 2011 with left-sided hemiparesis, non-Hodgkin's lymphoma, seizures, hypertension, frequent urinary tract infections, and kidney stones. The member has a body mass index of 26. He had previously been able to function at a modified independent level with a quad cane. He lives with his family in a single level residence without steps to the entrance. He has been attending outpatient therapy 2 times per week for left-sided strengthening. Functionally, he is dependent for bed mobility and requires maximum assistance for transfers. He was unable to ambulate when evaluated for therapy. He required moderate assistance for feeding and grooming and was dependent for toileting. The member is status-post left femur fracture with comorbid medical conditions as described above. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He has a new unilateral left lower extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member is limited by painafter his recent fall and surgery. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on July 26, 2018.You asked the Plan to pay forthe ambulance services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the claim was 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 the ambulance services was not filed until October 31, 2019. 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 forservices provided on July 26, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), bitewing x-rays (D0274), the initial periapical x-ray (D0220), 7 additional periapical x-rays (D0230), and the filling (D2335) provided from July 15, 2019 to August 7, 2019.You asked the Plan to pay forthe dental services. You say that you are only on social security income. You say that you cannot afford to pay this bill. You also say that you have provided your Medicaidcard so that they can be billed.The Plan denied your request. The Plan says the oral exam, bitewing x-rays, periapical x-rays, and the filling are not listed as covered services.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), bitewing x-rays (D0274), the initial periapical x-ray (D0220), 7 additional periapical x-rays (D0230), and the filling (D2335) provided from July 15, 2019 to August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 admission to an IRF does not meet criteria. Our physician reviewer found the member underwent a left great toe amputation on 03/13/2020 and was discharged home on the same day. His relevant past medical history includes stroke, Type II diabetes, hypertension, hyperlipidemia, a right ileostomy, and obstructive sleep apnea. The member lives in a 3 level residence with garage entrance with 11 steps to the entrance and 11 interior stairs. He had previously been independent. Prior to amputation he was receiving home-based physical therapy. On 03/11/2020 he was independent in bed mobility and required supervision for transfers. He was able to ambulate with a cane including outdoors. He required minimal assistance for upper body dressing. The member is status-post left great toe amputation without reported postoperative complication as described above. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He is currently in an outpatient setting and does not require an acute hospital level of care. The member requires physical therapy for mobility. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The member's medical conditions appear stable. He had been able to function at an independent level and would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 10, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 forthe medical services provided to the enrollee by an out-of-network provider on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe specialist office visit provided on September 17, 2019.You asked the Plan to waive the deductible forthe specialist office visit. You say that you should not have any member liability.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. Your contract with the Plan says that there is a $185 deductible that applies towards in-network specialist office visits. The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefitcategory. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $185 deductible that applies towards in-network specialist office visits. This cost sharing is a contractual obligation that had not been met at the time the specialist office visitwas received on September 17, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe specialist office visit provided on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on August 20, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you do not want to pay this amount every time you have a colonoscopy. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges andphysician or surgical charges. You have been asked to pay a $295 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 nothave to waive the copayment forthe colonoscopy provided on August 20, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 outpatient occupational therapy (OT) visits.You asked the Plan to pre-approve8 outpatient OT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 8 outpatient OT visits. Ourreviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the services of 8 visits in addition to the already approved OT visits are not proven to be specific and effective treatment for your condition. You have had prior approved OT and you are noted to be motivated to perform home exercises and has caregiver assistance. The services are not of a level of complexity and sophistication or your condition is not such that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The skills of a therapist are not needed to treat your illness/injury and can be carried out by non-skilled personnel. The request for 8 additional OT visits in addition to the already approved OT 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 8 outpatientOT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 outpatient occupational therapy (OT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe intravenous infusions provided from September 1, 2019 to September 10, 2019.You asked the Plan to waive the copayment forthe intravenous infusion. You say that Medicare should have some cost sharing for the services. The Plandenied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $295 copayment for the intravenous infusion at an outpatient hospital.You have been asked to pay a $184.19 copayment for the intravenous infusion on each date of service. ($184.19 x 2 dates of service = $368.38). The intravenous infusion falls within "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefitcategory. 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 forthe intravenous infusions provided from September 1, 2019 to September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on August 28, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the records do not indicate a clear provider intent to order the lab.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthedrug testing services provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 25, 2019.You asked the Plan to pay for the domiciliary or rest home visit.The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 a domiciliary or rest home visit provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy.You asked the Plan to pre-approveproton beam radiation therapy. You say that this is medically necessary and should be covered.The Plan denied your request. The Plan says this type of therapy is not known to be more effective than other types of therapy.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 proton beam radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy or image-guided radiation therapy. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home meal delivery service.

You asked the Plan to pre-approve Schwan home meal delivery service. You say that the services are necessary due to the Coronavirus. The Plan denied your request. The Plan says the requested service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Schwan home meal delivery service have not been met. Specifically, this is not a Medicare covered service as home delivered meals are not for diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, we decided that the Plan does not have to pre-approve home meal delivery service.