Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs are considered custodial.
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 physician reviewer found that you presented with complaints of having a hard time bending forward on account of chronic back pain and wearing oxygen. Due to your chronic medical conditions, you have a hard time walking and needs assistance with activities of daily living due to generalized weakness and deconditioning. You are currently holding on to walls and furniture when you walk, or get help from your husband. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 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 in this case, ongoing care needs include respiratory support with oxygen supplementation and BiPAP, neurologic monitoring, intravenous antibiotics, surveillance laboratory studies, transfusions as indicated, tight glucose control, tube feedings, and therapy services. 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 she is currently receiving care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided from November 14, 2019 to November 16, 2019.
You asked the Plan to pay for the skilled nursing services. You say that you were scheduled for discharge on November 14, 2019, but that your provider changed his mind and you were not released until November 16, 2019. You also say that you feel this claim is the responsibility of the insurance company. The Plan denied your request. The Plan says you did not require or receive continued daily therapy and/or daily skilled nursing services on these dates of service.
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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, developed C. difficile diarrhea and remained in the skilled nursing facility (SNF) for two additional days to ensure she could tolerate her antibiotics. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent to supervision level with functional mobility. The enrollee required varying assist with activities of daily living. She tolerated a regular diet and thin liquids. Our physician reviewer found that there were no identifiable skilled therapy service needs. There were identifiable skilled nursing service needs, but they were not required on a daily basis. We looked at this physician's review, the file, and Medicare rules. The records also show that you were advised that the SNF services in dispute would not be covered, and that you signed a Notice of Medicare Non-Coverage acknowledging this information was provided. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided from November 14, 2019 to November 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on February 11, 2020.
You asked the Plan to waive the copayment for the laryngoscopy. You say that the service was provided at the doctor's office. You say that you are being double charged. The Plan denied your request. The Plan says the copayment 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 $100 copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $100 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The laryngoscopy is considered a surgical procedure that was billed by the hospital. 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 laryngoscopy provided on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin C and other mineral infusions provided from March 20, 2019 to September 10, 2019.
You asked the Plan to pay for the vitamin/mineral infusions. You say that you feel this should be covered because you were told by your doctor that it would be helpful in treating your cancer. The Plan denied your request. The Plan says this is not an FDA approved treatment for cancer and cannot be covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the enrollee or provider, as applicable, is responsible for submitting sufficient information to support that criteria are met and payment is due. The documentation in the case file does not include medical records from the treating provider. It is limited to poor quality invoices which are not legible and do not indicate the dosage of the vitamins/minerals provided. Without this information plus information from laboratory testing, it cannot be determined whether Medicare coverage criteria are met. Therefore, we decided that the Plan does not have to pay for the vitamin C and other mineral infusions provided from March 20, 2019 to September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing provided on March 10, 2020.
You asked the Plan to pay for laboratory test. You say that you only perform this test in your hospital laboratory. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.
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 pay for laboratory test. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the lab test provided was medically reasonable and necessary to diagnose, treat, or otherwise manage the enrollee's condition(s). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory test have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent disease testing provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided January 28, 2020 to March 4,
2020.
You asked the Plan to pay for the dental services. You say that you were told that you would be reimbursed up
to $750 for services from a licensed dentist of your choice. You understand the dentist chose to opt out of
Medicare however she is still licensed. The Plan denied your request. The Plan says enrollee's must receive
their medical services from an in-network provider. The plan says that non-emergent services with noncontracted
providers require prior-authorization prior to services being rendered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. The file shows that the provider entered into a private contract
with you regarding payment. Therefore, we decided that the Plan does not have to pay for the dental services
provided January 28, 2020 to March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code E1038). 
 
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says it was not determined to be 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 the DME. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage for the transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code E1038). The documentation does not reveal that the patient has a mobility deficit that impairs participation in MRADLs in the home. The documentation does not indicates that the patient's mobility deficit is unable to be helped by the use of a walker, cane, or manual wheelchair. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code E1038).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee beginning at 1:58 PM on February 21, 2020 through February 22, 2020.
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically necessary. The Plan denied your request. The Plan says that post stabilization care was not approved.
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 the post stabilization inpatient care. Our reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case.
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. Our physician reviewer found that the patient was stable to transfer by ambulance to an in-network hospital. 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 post stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee beginning at 1:58 PM on February 21, 2020 through February 22, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee from February 4, 2020 to February 26, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that a corrected claim is needed due to incorrect coding.
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 has not substantiated their denial. The plan has not provided sufficient information on what information is needed on a corrected claim for it to be accepted. Therefore, we decided that the Plan has to pay for home health services provided to the enrollee from February 4, 2020 to February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic screening testing provided on November 12, 2019.
You asked the Plan to pay for genetic tests. You say that you are appealing with medical records to support the services billed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because HLA B57:01, 1CYP, CYP2C19, CYP2C9, VKORC1, CYP2D6, SLCO1B1, Factor 5 Leiden, and CYP2B6 are excluded from Medicare coverage and these tests are not covered in the absence of signs, symptoms, complaints, personal history of disease, or injury.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
There is no documentation in the record of a concern for a specific drug metabolism issue for which this testing was ordered. This was provided in the absence of signs/symptoms of a medical condition. This means it is screening in nature which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for pharmacogenomic screening testing provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on February 20, 2020.
You asked the Plan to waive the copayment for the echocardiography. You say that your doctor wanted this done prior to surgery. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayment 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 $20 copayment for Medicare-covered outpatient diagnostic procedures or tests. You have been asked to pay a $20 copayment for the echocardiography. The echocardiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as pre-operative testing. 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 echocardiography provided on February 20, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency room services (99284, 99283, 99282, 99285) provided July 3 to July 27, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary and provided by your facility. The Plan denied your request. The Plan says that the billing provider did not render the services at issue.
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 codes 99284, 99283, 99282, & 99285 are supported in the medical record. Specifically, the records provided note that the services were rendered by the billing provider. Based on this information, we decided that Medicare rules for coverage of the emergency room services have been met. Therefore, we decided that the Plan has to pay for emergency room services (99284, 99283, 99282, 99285) provided July 3 to July 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you had fallen at home and you called your primary care physician's office who advised you to call 911. You say that an ambulance came to your home and after evaluating you, they advised you that you did not appear to need serious medical attention. You stated that the paramedics suggested that you should avoid going to the hospital in order to limit your exposure to Covid-19. You say that because of this advice you decided to stay home and declined transportation. You stated that the Plan's denial is unfair because you would have had them take you to the hospital if you had known that the services would not be covered otherwise. You say that you were under the impression that you would only have to pay an ambulance copay.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the incontinence wipes. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99053) provided November 22, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not billed correctly.
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 99053 is not supported in the medical record. Specifically, the service was billed with an invalid place of service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99053) provided November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 5, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
non-emergent, 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
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 for diagnostic radiology services provided on February 5, 2020.