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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the admission criteria and his ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable discharge.The Plan denied your request. The Plan says the guidelines for coverage have not been met.The Plan says that the services the enrollee needs could be provided in another setting.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 is currently undergoing treatment at an acute care hospital (ACH) for an ischemic stroke. The enrollee is being treated for aspiration with antibiotics and pulmonary toilet. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 15, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were informed there was no copayment.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for Medicare covered physician specialist services.The enrollee has been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a specialist. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This costsharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chest x-ray, inpatient stay and ED visit provided on May 4, 2019, August 14, 2019 through August 17, 2019 and October 14, 2019 through October 15, 2019. You asked the Plan to waive the copayment forthe chest x-ray, inpatient stay and ED visit. You submitted your bill for review. You say that you want to know if you are responsible for the bill.The Plan denied your request. The Plan says the copayments 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 $45 copayment for in-network x-rays, $330 per day, days 1-5 foreach in-network inpatient stay and a $90 copayment for emergency care. You have been asked to pay a total of $1,125 for the chest x-ray, inpatient stay and ED visit. Date of ServiceServiceStandard CopaymentMember LiabilityMay 4, 2019Chest X-Ray$45$45August 14, 2019 -August 17, 2019Inpatient Stay$330/day$990October 14, 2019 -October 15, 2019ED Visit$90$90TOTAL:$1,125
The chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The inpatient stay falls within the "Inpatient hospital care" benefit category. The ED visit falls within the "Emergency care" 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 chest x-ray, inpatient stay and ED visit provided on May 4, 2019, August 14, 2019 through August 17, 2019 and October 14, 2019 through October 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 20, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment since you had to go to the emergency room due to the discomfort. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" 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 emergency room visit provided on September 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a commode chair and pail pan.
You asked the Plan to provide a commode chair and pail pan. You say that because of a recent surgery you need a commode by your bed. The Plan denied your request. The Plan says you are not room confined without facilities.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to provide a commode chair and pail pan.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran Emergency Room Visit and Electrocardiogram (99285, 93010) provided May 16, 2019.You asked the Plan to pay forthe Emergency Room Services. You say that the services were medically necessary and not work-related.The Plan denied your request. The Plan says workers compensation is liable for payment for the services at issue.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill Worker's Compensation. The records show the visit was the result of a work injury. As the secondary insurer, the Plan cannot be held responsible for the Emergency Room Services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay foran Emergency Room Visit and Electrocardiogram (99285, 93010) provided May 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to September 1, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilledservices that could not have been provided in an alternate setting other than a SNF.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 the skilled nursing services. 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to September 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction of teeth #19, 20, 21, 22, 27, 28, 29, and 30 (41899).You asked the Plan to pre-approve extraction of teeth #19, 20, 21, 22, 27, 28, 29, and 30. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 extraction of teeth #19, 20, 21, 22, 27, 28, 29, and 30. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this instance the requested treatment for removal of eight teeth is unrelated to any approved medical procedure that would be provided that would require these teeth to be removed. Section 140 of the Medicare Act also states "When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty". As the requested treatment is not to be provided in connection with a covered service, the extractions are not deemed to be a covered service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extraction of teeth #19, 20, 21, 22, 27, 28, 29, and 30 have not been met.Therefore, we decided that the Plan does not have to pre-approve extraction of teeth #19, 20, 21, 22, 27, 28, 29, and 30 (41899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 19, 2019 and October 3, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 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 subsequent nursing facility care provided on September 19, 2019 and October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions, complete maxillary denture, two removable prosthodontic procedures, and immediate mandibular denture provided on November 5, 2019.
You asked the Plan to pay for the extractions, complete maxillary denture, removable prosthodontic procedures, and immediate mandibular denture. You say that you were not aware that you were not enrolled in the optional dental rider provided by your plan. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 two extractions, complete maxillary denture, two removable prosthodontic procedures, and immediate mandibular denture provided on November 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 3, 2019 to September 24, 2019.You asked the Plan to waive the copayments for the physical therapy visits. You say that you do not have a copayment for the physical therapy. You say you did not receive the physical therapy at the hospital, but at a satellite location. 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 $40 copayment for physical therapy at an in-network outpatient hospital. You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 5 visits = $200). The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows you were billed by the outpatient hospital.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 3, 2019 to September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on October 14, 2019.You asked the Planto payforthe services. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says non-urgent services should be from network providers who are contracted with the members health plan and listed in the Provider DirectoryMedicare 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 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 Plandoes not haveto pay fordrug testing services provided to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on September 10, 2019.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The records show that you had a Medicare-covered eye exam on September 10, 2019. Medicare does not cover eye refractions as part of the exam. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 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 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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee needs long term custodial care with outpatient passive range of motion interventions.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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from September 24, 2019 through September 25, 2019.
You asked the Plan to pay for these drugs. You say that you did not request the drugs. The Plan denied your request. The Plan says that these are not Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from September 24, 2019 through September 25, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 10, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you requested a diabetic screening and did not know other laboratory services were rendered.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for non-preventative laboratoryservices. You have been asked to pay a $20 copayment for non-preventative laboratory services. Non-preventative laboratory services fall 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 forlaboratory services provided on October 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided October 13, 2019.You asked the Plan to pay forthe non-covered ambulance mileage. You say that you do not feel that you should be responsible becausethe provider did not have a heart doctor on staff and they wanted to send you to the nearest hospital but your doctors were elsewhere.The Plan denied your request. The Plan says only mileage to the nearest appropriate facility equipped to treat the enrollee is mileageThe plan follows Medicare rules. The rules say that Medicare pays for air or ground ambulance services only if the enrollee's medical condition is such that transportation by means other than an ambulance would not be appropriate.  The rules say that Medicare only pays for air or ground transport to the nearest facility that meets the enrollee's medical needs if the enrollee cannot be treated by the originating facility.The records show the enrollee was  successfully treated and requested transfer. There is no indication this facility could not meet the enrollee's medical needs. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage have not been met.Therefore, we decided that the Plan does not have to pay fornon-covered ambulance mileage (A0888) provided October 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to the enrollee on May 2, 2019.You asked the Plan to pay forthe services. You say that  The Plan denied your request. The Plan says The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services provided to the enrollee on May 2, 2019.