Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ferric carboxymaltose injection and IV infusion provided on August 14, 2019 and August 23, 2019.You asked the Plan to waive the cost share for the ferric carboxymaltose injection and IV infusion. You say that the hospital is a participating provider. You say that you should not owe anything.The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered Part B drug and a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a total of $677.84 for the ferric carboxymaltose injection and IV infusion.The ferric carboxymaltose injection falls within the "Medicare Part B Prescription Drugs" benefit category. The IV infusion falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 cost share for the ferric carboxymaltose injection and IV infusion provided on August 14, 2019 and August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from September 7, 2019 to September 8, 2019.
You asked the Plan to pay for inpatient care. You say that these services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable as of September 7, 2019.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the criteria for coverage of these inpatient services have not been met. Our physician reviewer found by 12:06 a.m. on September 7, 2019, the enrollee was stable for transfer to the nearest facility. By this time, the enrollee had undergone successful foreign body retrieval and was declared stable to be discharged home from the emergency department by the consulting physician. All lab results and diagnostic imaging confirm the enrollee's emergency medical condition had resolved. The review has determined that the post-stabilization care services at the non-Plan facility after 12:06 a.m. were not medically necessary and reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from September 7, 2019 to September 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 17, 2018 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you were told no authorization was needed. 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 the enrollee self-directed for service.
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 17, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 17, 2019 through August 29,2019 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that this should have been billed as inpatient rehabilitation with no copayment.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 shows that you were admitted on August 17, 2019 and discharged on August 29, 2019. You were asked to pay a $250 copayment per day from August 17, 2019 through August 23, 2019, days 1-7 of your inpatient stay. There were no copayment charges from August 24, 2019, day8 of your inpatient hospital care until your day of discharge August 29, 2019. Per your contract there is a $250 copayment per day required for days 1-7 for in-network inpatient hospital 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 does not have to waive the copayment for inpatient hospital care from August 17, 2019 through August 29, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoll LifeVest provided by an out of network provider on August 20, 2019.You asked the Plan to pay for the Zoll LifeVest. You say that you do not know when a prior authorization is required.The Plan denied your request. The Plan says there is no referral from the enrollee'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 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 Zoll LifeVest provided by an out of network provider on August 20, 2019.
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 requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the acute care hospital on 3/2/20, after being found down at home. His diagnoses include Pneumonia, unspecified organism, Severe sepsis with septic shock, Urinary tract infection, site not specified, Acute kidney failure with tubular necrosis, and Type 2 diabetes mellitus with hyperglycemia. The enrollee developed worsening respiratory distress in the hospital, and required intubation. An IV pressor was started for hypotension. On 3/15/20, it is documented in the Critical Care Progress Note that the enrollee's prognosis is guarded to poor.Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care,and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that the enrollee is likely to benefit from, and improve with, care in an LTACH. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 for outpatient hospital services provided on August 14, 2019 through August 28, 2019.You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99203 is not recognized by OPPS when submitted on an outpatient hospital Part B bill type.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the record. Specifically, CPT code 99203 has a status indicator of B meaning that it is not recognized by OPPS when billed on an outpatient hospital Part B bill type. This claim was submitted on outpatient hospital Part B type, 131. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on August 14, 2019 through August 28, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lisinopril (J8499).
You asked the Plan to pre-approve the Lisinopril. You say that this drug is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B because it is a drug that is meant to be taken orally.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lisinopril (J8499).
Benefits for the Lisinopril 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a True balance seat power tilt and True balance tilt and recline (E2617, E2609).You asked the Plan to pre-approve a True balance seat power tilt and True balance tilt and recline. You say that the items are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 a True balance seat power tilt and True balance tilt and recline. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items appear to exceed your medical need. The documentation does not reveal that you have a significant postural deformity or need for a custom seating system rather than a prefabricated one therefore this request is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a True balance seat power tilt and True balance tilt and recline have not been met.Therefore, we decided that the Plan does not have to pre-approve a True balance seat power tilt and True balance tilt and recline (E2617,E2609).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary.The Plan denied your request. The Plan says the requested Aranesp does not meet criteria.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 Aranesp. Our reviewer says that the requested Aranesp does not meet criteria. Our physician reviewer found the enrollee is diagnosed with anemia due to myelofibrosis. There is non-coverage for bone marrow fibrosis and the enrollee is documented as having myelofibrosis. However, the enrollee appears to have been responding to aranesp but there is no documentation provided to explain if transfusions have been needed or not. The service is not reasonable or medically necessaryat this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 6, 2019 through July 18, 2019.
You asked the Plan to waive the copayment for inpatient hospital 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).
Your plan has an annual maximum out of pocket is $3,200. The maximum out of pocket was not satisfied on the date of service, the claim was processed correctly with correct copayment amount. 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 inpatient hospital care from July 6, 2019 through July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-discountable item and warranty (V2797) purchased November 30, 2019.
You asked the Plan to pay for non-discountable item and warranty. You say that you must assume that this claim is for the glasses and lenses that you purchased. It has been more than 2 years since your last frames and lenses so how can it be denied. The Plan denied your request. The Plan says this service is not a covered benefit.
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 the plan covers 1 routine eye exam a year and $100 allowance for frames, or contact lenses instead of eyeglass lenses.
We looked at the file and the Plan's rules. The non-discountable item and warranty is not covered by the plan. The rest of the claim was processed and paid in accordance to the plan benefits. Based on this information, we decided that the Plan's rules for coverage of non-discountable item and warranty have not been met. Therefore, we decided that the Plan does not have to pay for non-discountable item and warranty (V2797) purchased November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve the physician's services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.
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 physical therapy provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (A4245, A4927, G0151, G0152, G0153, and G0299) provided on October 10, 2019 to October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for home health services. You say that these services should be paid.The Plan denied your request. The Plan says these services were not authorized by the Plan.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 home health services (A4245, A4927, G0151, G0152, G0153, and G0299) provided on October 10, 2019 to October 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 26, 2019 to July 29, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford 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 $395 copayment for each day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from July 26, 2019 to July 29, 2019. Therefore, you are responsible to pay a $395 copayment for days 1-3 (July 26, 2019 to July 28, 2019). $395 (copayment) x 3 (inpatient days) = $1,185.You have been asked to pay the total copayment amount of $1,185 for an inpatient hospital stay. An inpatient hospital 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 July 26, 2019 to July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 18, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 18, 2019.