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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 12, 2019 through August 20, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were misdiagnosed in the emergency room and had to be admitted to the hospital as a result. 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 12, 2019 and discharged on August 20, 2019. You were asked to pay a $250 copayment per day from August 12, 2019 through August 18, 2019, days 1-7 of your inpatient stay. There were no copayment charges from August 19, 2019, day 8 of your inpatient hospital care until your day of discharge August 20, 2019. Per your contract there is a $250 copayment per day required for days 1-7. 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 12, 2019 through August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says you cannot tolerate an intensive rehab program and are not medically or functionally complex enough to require intensive rehab setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from April 11, 2019 to October 31, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 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 service 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 physician's services provided from April 11, 2019 to October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the member tripped on a carpet at home and fell onto her right hip sustaining an intertrochanteric femur fracture. She underwent a non-cemented right total hip arthroplasty and open reduction with internal fixation of the greater trochanter. She is weight-bearing as tolerated. The member lives in a two-level residence without steps to the entrance and 12 steps to a second floor bedroom and had been independent. Functionally, she requires maximum assistance x2 for bed mobility and moderate assistance x2 for transfers and when ambulating 8 feet with a rolling walker. She has poor standing and fair seated balance. She has decreased bilateral upper and lower extremity strength. The member is status-post right intertrochanteric femur fracture as described above. The member's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment after her hip surgery. She has a new unilateral lower extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member is limited by pain after her recent surgery. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 2/9/20 with respiratory distress. The enrollee suffered a stroke in December 2019, and required placement of a tracheostomy and a PEG tube. She is non-ambulatory. Diagnoses include end-stage renal disease (ESRD) with dependence on renal dialysis, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and paroxysmal atrial fibrillation. On 2/10/20, notes are conflicting. It was documented that the enrollee was non-verbal, and did not respond to stimuli overall. It was also documented the enrollee was oriented to time, person and place. An occupational therapy (OT) evaluation on 2/10/20 documented total care for dressing, bathing, toileting, and eating. An OT frequency of 3-4 days per week was recommended. The physical therapy (PT) note on 2/12/20 documented total assist for basic mobility. The enrollee was unable to follow commands. On 2/18/20 it is documented in the nephrology consultation note that a less aggressive level of care, including palliative care or hospice may be appropriate.
The enrollee is dependent and requires skilled nursing services. The documentation does not support that skilled therapy services are medically necessary and reasonable for the enrollee at this time. It is not documented that discharge to a SNF is a safe and appropriate disposition for 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833) and suspension sleeve (L2397) provided to the enrollee on November 19, 2019.You asked the Plan to pay forthe orthosis and sleeve. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee has previously received the same items from a different provider that is still within the 5-year RUL.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same orthosis and sleeve from a different provider on November 4, 2019. This orthosis and sleeve are still within the 5-year RUL and the documentation submitted does not show that the orthosis and sleeve are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the knee orthosis and suspension sleeve at issue.  Based on this information, we decided that Medicare rules for coverage of the orthosis and sleeve have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1833) and suspension sleeve (L2397) provided tothe enrollee on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for SNF care provided to the enrollee from March 29, 2019 through May 4, 2019 by an out-of-network provider.
You asked the Plan to waive the cost-share for SNF care. You say that you were never advised that the facility being used is not in-network. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received SNF care from March 29, 2019 through May 4, 2019 by an out-of-network provider. At the time of services rendered the enrollee had not met their $599 deductible; therefore, the enrollee has been asked to pay $599 for the services to apply to their deductible. The enrollee met their deductible and are asked to pay 50% coinsurance for the out-of-network SNF care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for SNF care provided to the enrollee from March 29, 2019 through May 4, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF care. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient does not meet criteria for IRF admission. She may benefit from further therapy but cannot tolerate an intensive therapy program. IRF admission is not medically necessary based on her current functional status and activity tolerance.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is at her functional baseline, and is not appropriate for skilled therapy at this time.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for skilled nursing services. The provided medical records do not indicate a need for skilled therapy services. There is no need for daily skilled services. There is no need for inpatient services. Care in the long term care facility with custodial care and intermittent services appears to be appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on September 11, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you met the out-of-pocket limit for inpatient care after services in March and May of 2019. The Plan denied your request. The Plan says the cost-sharing for the October claim is appropriate as it is an outpatient procedure, and you had not reached the out-of-pocket limit prior to the September date of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Upon initial receipt of the appeal, review of your history was conducted to verify the nature of the services performed. It was noted after review of your 2019 claims that you had been previously admitted inpatient in January of 2019 for a three-day stay. However, subsequent hospital visits in March, May and October were performed on an outpatient basis, and therefore do not apply towards the $750 out-of-pocket limit for inpatient services. A s referenced in Chapter 4, page 73-74 of your 2019 EOC, there is a $150 co-pay for days 1-5 of every Medicare-covered inpatient stay, with a $750 out-of-pocket yearly limit. Since this limit was met during your second inpatient admission in September, the claim was reprocessed to reduce the co-pay to $300. The new claim 191121962419 was created and payment was issued to the provider on November 21, 2019. 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 on September 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission
You asked the Plan to pre-approve these services. You say that the enrollee needs strength training to gain independence. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 10, 2020 with a fall and left hip pain. She was diagnosed with a urinary tract infection and received three days of antibiotics. She is walking 40 feet with assistance. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you depend on the hospital staff to verify eligibility and to obtain the proper authorization for in and out of network providers from the enrollee's insurance. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says another out of network provider referred the enrollee for the services. The Plan also says the services could have been provided in network.
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 provider in this case is not a network provider with the Plan. The referring facility is not a network provider either. 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 subsequent nursing facility care provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device. You asked the Plan to pre-approve continued coverage of the CPAP device (E0601). You say that the enrollee is compliant and needs to continue to use the CPAP. The Plan denied your request. The Plan says the enrollee has not had a follow-up appointment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The enrollee has not had a re-evaluation documenting that they are benefiting from the CPAP. Based on this information, we decided that Medicare rules for coverage of continued coverage of the CPAP device (E0601) have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on
July 9, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says they were unable to discover any evidence of an established
relationship between the member and the ordering physician. The Plan states there were no claims submitted
for an evaluation and management service. The Plan states the review of claims history for this member, and a
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service
with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis
(L0650) provided to the enrollee on July 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy visits.
You asked the Plan to pre-approve ten additional physical therapy visits. You say that this treatment 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 medically necessary outpatient therapy. Based on the medical records provided, the enrollee is a resident with a community care hospital. The medical records do not show the enrollee requires continued treatment. The records show the enrollee has normal range of motion and has met the strength goals. Medicare rules for coverage of ten additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy visits.