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 member cannot go home at this time as their spouse in unable to care for them alone. The Plan denied your request. The Plan says the member's necessary care may be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the services available and covered atthe current facility are sufficient, and there are no additional services needed that only the LTACH would offer.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 and duplex scan provided on August 22, 2019.You asked the Plan to waive the copayment forthe office visit and duplex scan. You say that you should only be responsible for the higher copayment. You say that you should not be responsible for the additional $95.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 $40 copayment per visit for a specialist office visit and a $55 copayment for each Medicare-covered standard x-ray and ultrasound. You have been asked to pay a $40 copayment for the office visit and a $55 copayment for the ultrasound. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The duplex scan 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 office visit and duplex scan provided on August 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from September 19,
2019 through September 24, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share
responsibility for the services you received due to not received the service you were supposed to. The Plan
denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received SNF care provided from September 19, 2019 through September 24,
2019. You are asked to pay a $20 copayment per day for SNF care. Your EOC clearly states, for each
admission you pay $20 per day for days 1-20 of a benefit period, $60 per day for days 21-44, and $0 per day
for days 45 -100 of a benefit period. 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 SNF care provided
from September 19, 2019 through September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from September 1, 2019 through September 11, 2019.You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from July 17, 2019 to September 11, 2019. You did not have a copay for days 1-20, but you are asked to pay a $156 copayment per day for days 21-100 of SNF care. 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 doesnot have to waive the copayment for SNF care from September 1, 2019 through September 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass grafts (93925) provided on August 28, 2019.You asked the Plan to pay forduplex scan of lower extremity arteries or arterial bypass grafts. You say that this should be covered.The Plan denied your request. The Plan says this was a screening test and is not covered by Medicare or the Plan.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, duplex scan of lower extremity arteries or arterial bypass grafts, was billed with diagnosis codes that indicate it was requested for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forduplex scan of lower extremity arteries or arterial bypass grafts (93925) provided on August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an out-of-network x-ray (73630) and a surgical boot (L3260) provided on October 22, 2019.
You asked the Plan to waive the coinsurance for an out-of-network x-ray and a surgical boot. You say that you were told this provider was in-network. The Plan denied your request. The Plan says these services processed 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 40% coinsurance for out-of-network diagnostic procedures and tests and a 25% coinsurance for out-of-network prosthetics. You have been asked to pay $12.01 ($30.03 allowed amount x 40% = $12.01) for an x-ray, which is a diagnostic procedure, and $3.13 ($12.51 allowed amount x 25% = $3.13) for a surgical boot, which is a prosthetic. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network x-ray (73630) and a surgical boot (L3260) provided on October 22, 2019.
Your complaint about the provider not confirming network status is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forseat lift mechanism (CPT Code E0627) purchased by the enrollee on September 11, 2019 from a non-certified DME provider.You asked the Plan to pay forthe DME. You say that the member is unable to get into or out of a chair on his own.The Plan denied your request. The Plan says the member chose not to use their hospice benefit.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 member was being cared for by hospice services starting on January 4, 2019. Hospice services continued until October 31. 2019. During that time the enrollee purchased a recliner with a seat-lift mechanism. This seat-lift is classified as DME. DME needed in hospice are managed as rentals. The enrollee chose not to utilize this hospice benefit. The enrollee purchased a recliner with a seat-lift mechanism. The enrollee purchased this from a local furniture store. This was not purchased from a certified DME supplier. The enrollee has submitted a receipt to be reimbursed for their purchase. The Plan is not responsible for the cost of this recliner. 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 Plan does not have to pay forseat lift mechanism (CPT Code E0627) purchased by the enrollee on September 11, 2019 from a non-certified DME provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on May 2, 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 drug testing rendered to the enrollee on May 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 8, 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 forthe drug testing rendered to enrollee on August 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (LSO) rendered to the enrollee on October 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that replacement due to wear is not covered during the reasonable useful lifetime of the equipment.We looked at the file and Medicare rules. The file shows that the enrollee previously received an LSO on May 24, 2017 for which the Plan approved and paid. The approved LSO was not irreparably damaged and was not more than five years old; therefore, the LSO rendered on October 7, 2019 is not covered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis (LSO) rendered to the enrollee on October 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided April 1 to April 5, 2019.
You asked the Plan to pay for the inpatient services. You say that the DRG submitted is correct. The Plan denied your request. The Plan says the DRG is not submitted by the records provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG J15.6 is defined as Pneumonia due to other aerobic Gram-negative bacteria. In this case, you billed the services provided April 1 to April 5, 2019 with DRG J15.6. 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 inpatient services. Our reviewer says that the DRG billed is not supported in the records. Our physician reviewer found the documentation did not reflect fever, leukocytosis, or purulent sputum. The documentation did not accurately reflect the diagnosis of pneumonia due to other aerobic Gram-negative bacteria. The documentation accurately reflects the diagnosis of pneumonia but not specifically due to a Gram negative organism. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG J15.6. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided April 1 to April 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayments for radiation therapy services provided by provider from June 30, 2019 through August 2, 2019.You asked the Plan to waive the copayments for radiation therapy services. You say that you did not see a specialist during each visit. You say that these were billed in error.The Plan denied your request. The Plan says that the cost share applied correctly.The Plan must follow Medicare rules.The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records do not support how the cost share was applied.Therefore, we decided that the Plan has to waive the copayments for radiation therapy services provided by provider from June 30, 2019 through August 2, 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: 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 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 enrollee was admitted
to acute care on 2/17/20 after presenting to the emergency room with complaints of not being able to walk, and
tremors in her arms and her legs and complaints of involuntary movements of her head and neck. The enrollee
has been diagnosed with tremor, ataxia, and chronic hypertension and has a history of osteoarthritis, depression
and anxiety, history of lung and breast cancer, and chronic back pain with degenerative disc disease involving
lumbar spine and cervical spine. On 2/25/20 the enrollee ambulated 100 feet with contact guard assistance with
a rolling walker. On 2/26 the enrollee's bed mobility was at a standby assistance level, supine to sit was at a
standby assistance level and the enrollee ambulated 120 feet with contract guard assistance x 1 with walker.
The enrollee was noted to be progressing towards goals but limited by decreased activity tolerance. The
enrollee had no complaints and vitals were stable on 2/26/20. She was noted on 2/24 and 2/25 also to be feeling
better.
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that
the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision.
The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but
the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level
in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission.You asked the Plan to pre-approveinpatient hospital admission. You say that the services are medically 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 inpatient hospital admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. They were noted to be generalized weak without focal findings. There were no advance interventions or complex medical conditions. They had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by the documentation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital admission have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient hospital admission.
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 will benefit from the services to address performance deficits and to maximize independence with activities of daily living(ADLs).The Plan denied your request. The Plan says the enrollee does not meet criteria for a LTACH admission.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 that as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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