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

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on November 2, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that these should be covered. You say that you did not ask for these tests to be done. 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 $85 copayment for outpatient diagnostic tests/radiological diagnostic services.

You have been asked to pay a $85 copayment for an ultrasound of the heart and $84.71 for an abdominal ultrasound. The total amount you are being asked to pay is $169.71 ($85 + $84.71 = $169.71). The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 an ultrasound provided by a participating provider on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 29, 2020, through July 1, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that treatment could have been provided at a lower level of care, such as observation.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then, a 69-year-old female with a history of anxiety, opioid use disorder/relapse - heroin, nicotine and alcohol dependence, osteoarthritis, osteoporosis, cerebral aneurysm, hypothyroidism, low back pain, emphysema who was hospitalized due to abdominal pain, nausea and vomiting. The enrollee stated that the symptoms were those she has when withdrawing from heroin. She stated it has been 3 days since using when the symptoms started. The enrollee stated she was taking Methadone 15 mg daily that was administered at the Methadone Clinic daily. According to hospital records/discharge summary forms, the enrollee was transferred to the hospital by ambulance with c/o abdominal pain 10/10, nausea and vomiting. The enrollee stated she had taken Suboxone prior to this onset. She reports last used heroin one month ago. According to the discharge summary, the enrollee reported being a daily heroin user and had used the day prior to this admission. The report also indicated the abdominal pain was consistent with opioid withdrawal. Her condition was treated, her condition stabilized and improved and she was discharged home when considered medically stable. The review indicates that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 29, 2020, through July 1, 2020.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 11, 2020,
to November 11, 2020.

You asked the Plan to pay for the 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
required no nursing services which would be considered skilled services by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to 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 for the skilled nursing services provided from October 11, 2020, to November 11,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84443) provided July 28, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the lab tests were for screening purposes and 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 lab services (84443) provided July 28, 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show the enrollee has not completed the full course of treatment in the hospital because he continues to exhibit nausea and vomiting which limits skilled therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for kidney stones, hydronephrosis, renal insufficiency and gallbladder surgery. The enrollee's medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from November 5, 2020, through December 4, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could have been provided at a lower level of care (ex. home, AL, LTC).

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the SNF services provided from November 5, 2020, through December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and Part B drugs you
received on December 23, 2020.

You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible
for the cost share.

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 $15
copayment for each primary care office visit. Your contract also says that you must pay a 20% coinsurance for
Part B drugs.

Review of the file shows that you had a primary care office visit and were provided Part B drugs on December
23, 2020. You have been asked to pay a $15 copayment for the office visit. The visit falls within the physician
services benefit category. You have also been asked to pay a 20% coinsurance for the Part B drugs, totaling
$0.38. 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 cost share for the office visit and Part B drugs you received on
December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says enrollees are allowed 20 one-way medical transportation trips per calendar
year.

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. The Plan covers a maximum of 20 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 20, 2020, through July
26, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
the inpatient service was not medically necessary. The care could have been provided at a lower level of
service.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the enrollee has history of lymphedema of bilateral lower extremities and history of
osteomyelitis of the shoulder on chronic a suppressive antibiotic therapy who presented to the ED with 
complaints of bilateral lower leg redness and pain x2 days. He reported that he had a history of cellulitis 
and his PCP told him to come to the ED. In the ED, the enrollee was afebrile and vital signs
were within normal limits. Physical exam showed cellulitis of B LE R>L from knee to ankle. Labs showed
WBC count of 12.5, Na- 132, BUN/Cr-15/0.7, CRP-16.6 and BS-133. A review of systems stated the
cardiovascular system was negative for chest pain and leg swelling. Skin was positive for color change but
negative for rash. The medical records stated that the enrollee was not in acute distress. He was admitted to the
hospital and treated with IV antibiotics and Lasix for lower extremity swelling. He responded well to treatment.
Blood cultures remained negative. He remained hemodynamically stable and was discharged home when 
considered medically stable. The review has determined that the record showed that at the time of
the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care
(including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided July 20, 2020, through July 26, 2020.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member will benefit from an acute level facility
versus the low level of care that she will receive at the hospital. The Plan denied your request. The Plan says
that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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 in the Medicare rules section.

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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hypercalcemia,
weakness, dizziness and dehydration. The enrollee's medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital surgery services
provided on September 21, 2020.

You asked the Plan to waive the copayment for outpatient hospital surgery services. You say that you believe
this service should be covered. The Plan denied your request. The Plan says the copayment amount you are
being charged is correct.

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 $325
copayment for outpatient hospital surgery services for Outpatient Hospital Services.

You have been asked to pay a $325 copayment for surgery services for outpatient hospital surgery services.
Outpatient hospital surgery services falls within the Outpatient Hospital 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 outpatient hospital surgery services provided on September 21,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on December 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on December 16, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 18, 2020, through October 6, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the enrollee's medical treatment could have been provided at a lower level of care such as observation.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee was a then, a 70-year-old male who presented to the emergency department (ED) on September 18, 2020 with worsening confusion. He was noted to be disoriented and muttering to himself. He received intravenous fluids and medication adjustments. He was admitted and evaluated by geriatrics and physical therapy. CT of abdomen and L spine did not show any acute finding. His mental status improved with hydration and he was discharged on October 6, 2020 when he was considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 18, 2020, through October 6, 2020.

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.