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 you need to be in an LTACH because
you have COVID and pneumonia. You say that you cannot even eat without his oxygen cropping. You say that
you are in bad shape and need external help and more therapy to recover. The Plan denied your request. The
Plan says the records do not show it is medically necessary to be in an LTACH in place in of an acute care
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for
COVID-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services
that are not currently available. 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 26, 2020.You asked the Plan to pay forthe services. You say that the provider said the accepted this insurance.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on May 5, 2020.You asked the Plan to pay for the emergency room services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related tothe terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for emergency room services provided on May 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the LTACH services are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of LTACH services.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 patient does not require services at the LTACH thatare not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued home health aide services.You asked the Plan to pre-approvehome health aide. You say that no one in your home is capable of performing basic tasks without assistance, and you recent had surgery.The Plan denied your request. The Plan says the denial of authorization for home health care is correct.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health aide. Our reviewer says that you do not meet the Medicare criteria for the requested home health aide services. Our physician reviewer found there areno recent medical records to substantiate your functional status or the medical necessity for home health services. You did not have hands-on personal care needs documented in the records that required a home health aide to maintain your health. There arealso no identifiable skilled nursing or skilled rehabilitation needs documented.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids (V5260) provided on February 26, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe hearing aids. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the provider that performed these services is not in network.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 they are rendered by a network provider.
We looked at the file and the Plan's rules. The file indicates that you did not receive these services from a network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids (V5260) provided on February 26, 2020, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care.You asked the Plan to pre-approveinpatient mental health care. You say that continued inpatient care is medically necessary.The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 therequest to pre-approve inpatient mental health care. Our reviewer says that the criteria for inpatient care have not been met. Our physician reviewer found it does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the skilled nursing facility (SNF) care provided.

You asked the Plan to waive the co payment for the SNF care. You say that the previous facility that used up your days without SNF co payment did not provide adequate care and you would like to be compensated.The Plan denied your request. The Plan says the cop ayment applied correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 co payment for days 1 to 20, a $178 co payment for days 21 to 100 for skilled nursing facility care. 

You have been asked to pay a total cost share of $1246 (days 21-27x $178 co payment). Of note, you previously had used up 15 SNF days at a previous SNF visit within the benefit period. Therefore, April 28 was day 16 of SNF coverage. The services provided fall within the skilled nursing facility 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 co payment for the skilled nursing facility (SNF) care provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided.

You asked the Plan to pay for the dental services. You say that you had a dental appointment for routine x-ray and cleaning. You say that your booklet states that these services are covered with a $0 co payment. You say that you do not remember reading anything about only certain x-rays are covered. You also say that you used your insurance the way that you thought you could.The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says

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 initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea transthoracic echocardiogram for the enrollee.You asked the Plan to pre-approvea transthoracic echocardiogram.You say that an echocardiogram is medically necessary.The Plan denied your request. The Plan says that medical necessity has not been established.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 an echocardiogram. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with dyspnea and new onset atrial fibrillation. As partof the normal evaluation for new onset atrial fibrillation, an assessment of LV function, atrial size and valvular heart disease (particularly mitral valve disease) by transthoracic echocardiography is appropriate and indicated.  A transthoracic echocardiogram in this clinical situation (at initial diagnosis) is therefore appropriate, medically necessary and meets CMS coverage criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an echocardiogram have been met.Therefore, we decided that the Plan has to pre-approvea transthoracic echocardiogram for the enrollee.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 toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99214) and a fluorescein angiography procedure (92235) performed on June 18, 2020.
You asked the Plan to waive the copayments for a specialist office visit and a fluorescein angiography procedure. You say that you have never been charged 2 copayments for 1 visit to the provider's office. The Plan denied your request. The Plan says the correct copayments were 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 $40 copayment for each visit to an in-network specialist for Medicare-covered services and a $40 copayment for each Medicare-covered X-ray visit and/or simple diagnostic test. You have been asked to pay a $40 copayment for a specialist office visit and a $40 copayment for a fluorescein angiography procedure. A specialist office visit falls within the "Physician services, including doctor's office visits" benefit category. A fluorescein angiography procedure 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 copayments for a specialist office visit (99214) and a fluorescein angiography procedure (92235) performed on June 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of osteocel graft (mesenchymal stem cell therapy).You asked the Plan to pre-approveosteocel. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the clinical value and effectiveness of osteocel has not been established.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 osteocel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found osteocel graft is experimental for use in cervical spine surgery. More research is needed to show its safety and efficacy. The gold standard is iliac crest autograft.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of osteocel have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of osteocel graft (mesenchymal stem cell therapy)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF admission. You say that SNF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in aSNF 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found theenrollee does not require skilled nursing or skilled therapy services on a daily basis.  This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.Medicare coverage criteria are not met. 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 23, 2020, by an OON
provider.
You asked the Plan to pay for a domiciliary or rest home visit and advance care planning. You say that these
medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The
Plan says rules for payment have not been met.
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 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 June 23, 2020,
by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe skilled nursing facility (SNF) services you received from April 1, 2020, to April 30, 2020.You asked the Plan to reduce the copayment forthe SNF services. You say that you are being charged too much for these services.The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan states that you did not meet your annual Out-of-Pocket Maximum until after these services were rendered.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 $0 copayment per day for days 1-20, and a $150 copayment per day for days 21-100 for skilled nursing facility services. Recordsshow that you were in the SNF from March 6, 2020, to May 30, 2020, which is a total of 85 days.  For days 1-20 (March 6-March 26), you were charged a $0 copayment per day.  Starting on March 27, you were charged a $150 copayment per day until you hit yourannual Out of Pocket Maximum. You have been asked to pay a $0 copayment per day for days 1-20, and a $150 copayment per day for days 21-100 for the SNF services. This means that you have been asked to pay the correct amount based on your contract with thePlan. 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 reduce the copayment forthe skilled nursing facility (SNF) services you received from April 1, 2020, to April 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation exceeding 50 miles.
You asked the Plan to pre-approve the routine transportation exceeding 50 miles. You say that you are in pain
and need to see the requested specialist. The Plan denied your request. The Plan says the requested
transportation exceeds the benefit allowance.
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 routine transportation when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the location you are
requesting routine transportation to is approximately 77 miles from your home address. Therefore, we decided
that the Plan does not have to pre-approve routine transportation exceeding 50 miles.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 7, 2020 by an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without 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 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 April 7, 2020 by an out of network (OON) provider.