Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for inpatient hospital care from December 27, 2019 through December 30, 201. We decided that the Plan does not have to pay for inpatient hospital care from December 31, 2019 through January 29, 2020.
You asked the Plan to pay for inpatient hospital care from December 27, 2019 through January 29, 2020. You say that the stay was medically necessary. The Plan says that the stay is not medically necessary.
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 for inpatient hospital care from December 27, 2019 through January 29, 2020. Our reviewer says that the documentation partially supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the time in the hospital was prolonged because family would not accept the enrollee back in the home and other placement was necessary. The record does show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. Inpatient admission from December 27, 2019 through December 30, 2019 was medically necessary. However, the remainder of the hospital stay (December 31, 2019 through January 29, 2020) was custodial, as the record clearly documents that the enrollee was stable for discharge when placement became available.
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 care have partially been met.
We decided that the Plan has to pay for inpatient hospital care from December 27, 2019 through December 30, 2019.
We also decided that the Plan does not have to pay for inpatient hospital care from December 31, 2019 through January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you previously had a shower chair which is now broken. You say that you need the requested shower chair in order to help you shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November
13, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that a surgery went wrong and
you feel that you should not be responsible for the charges. 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 $225
copayment for ambulance services.
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the
ambulance 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 ambulance services
provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unlisted procedure on dentoalveolar structure
(41899) and anesthesia for intraoral procedures (00170).
You asked the Plan to pre-approve the unlisted procedure on dentoalveolar structure and the anesthesia for
intraoral procedures. You say that the enrollee has been trying to get this surgical procedure done since
February 2020 and is in an extreme amount of pain. You say that the enrollee has been taking antibiotics for
several months. The Plan denied your request. The Plan says the requested codes are not codes covered per the
enrollee's supplemental dental coverage.
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 pre-approve an
unlisted procedure on dentoalveolar structure (41899) and anesthesia for intraoral procedures (00170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 18, 2019 by a non-contracted provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on July 18, 2019 by a non-contracted provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you do not require complex daily nursing care and daily skilled rehabilitation therapy.
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 your 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening tests provided on December 16, 2019.
You asked the Plan to pay for genetic tests. You say that you are requesting payment of this claim. The Plan
denied your request. The Plan says the denial of payment for these services is correct, because these tests are
not covered by Medicare for the diagnosis billed.
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 tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
genetic screening tests provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
December 11, 2019 to December 18, 2019.
You asked the Plan to waive the copayment for inpatient stay. You say that you were told this stay would be
fully covered and you are on a limited income. 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 $275
copayment per day for days 1 to 6 and nothing after day 6 for inpatient stay. At the time this claim was
processed, $2,407.73 of the $3,600 maximum out-of-pocket amount had been met. This inpatient stay lasted 7
days, resulting in a copayment obligation of $1,192.27 because this amount met the $3,600 maximum out-ofpocket
amount for 2019.
You have been asked to pay $275 copayment per day for days 1 to 6 and nothing after day 6 for inpatient stay,
up to the $3,600 maximum out-of-pocket amount for 2019. Inpatient stay falls within the Inpatient Hospital
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 an inpatient hospital stay
provided from December 11, 2019 to December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 20, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an urgent care visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for Urgently needed services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an urgent care visit on January 20, 2020. You have been asked to pay a $25 copayment for the urgent care visit. The urgent care visit falls within the Urgently needed 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 urgent care visit provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 24, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
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
laboratory services. 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 laboratory services provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the Medicare Part B drug provided on August 29, 2019. We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug provided on November 14, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you should not owe anything beyond the $35 copayment. You also state that you did not receive an injection on August 29, 2019. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to waive the coinsurance for the Medicare Part B drug provided on August 29, 2019.
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 plan did not provide medical records showing whether or not a Medicare Part B injection was received on August 29, 2019. Therefore, we decided that the Plan has to waive the coinsurance for the Medicare Part B drug provided on August 29, 2019.
We also decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug provided on November 14, 2019.
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 20% coinsurance for Medicare Part B drugs. The allowed amount is $3.70 and 20% of that is $.74. Therefore, we decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug provided on November 14, 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 long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 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 CoViD-19 complicated by renal failure and infectious diarrhea. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. The enrollee still appears to be acutely ill. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and 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 (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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from
August 1, 2019 to September 23, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file, Medicare rules, and the Plan's rules. Based on this information, we decided that
Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided
that the Plan does not have to pay for the home infusion therapy services (S9328) provided from August 1,
2019 to September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 5, 2019 to December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient surgeries. You say that these services do not require authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the plan and there was no referral from the enrollee's in-network 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 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 for the medical services provided on December 5, 2019 to December 19, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that the enrollee has had three
recent surgeries that have prevented her from being able to walk or be transported by regular wheelchair to
follow-up appointments and outpatient dialysis services. The Plan denied your request. The Plan says a
physician's office is not a Medicare approved destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Protonix 40mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial as this is the only medication that has worked for the member with an increase of dosage. The
Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual
policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Protonix 40mg tablet
medication.
Benefits for this medication 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: 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-approve SNF 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 this enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter this enrollee does not require the necessary services on 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-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses and frames purchased December 3, 2019.
You asked the Plan to pay for the vision services. You say that when you went to the provider they told that you would be reimbursed up to $175. You believed the provider and had you known you would not have gone this route purchasing the glasses. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider and progressive lenses is not covered by the plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you get your care from network providers. We looked at the file and the Plan's rules. vision services must be provided from a network provider. The plan does not cover for extra pairs of glasses, bifocal/trifocal lenses without lines and progressive bifocals/trifocals, protective coating for plastic lenses, and contact lens supplies. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses and frames purchased December 3, 2019.