Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care services provided on August 11, 2019.You asked the Plan to pay for the urgent care services. You say that you were out of town with no connection to any doctor when you experienced a sudden extreme headache and a bloody nose with a blood pressure of 160/105. You say that you were seen at the urgent care facility which you believe saved your life. The Plan denied your request. The Plan says the services received were not emergent/urgent and were not authorized.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  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 urgent care services. Our reviewer says that the urgent care services are not medically reasonable and necessary. Our physician reviewer found that there is no narrative record from the urgent care facility has been submitted for review. The submitted intake form does not note a headache or a bloody nose, and the vital signs include a normal blood pressure. As such, there is insufficient evidence to support that the provided services were either emergent or urgent.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 urgent care services have not been met. Therefore, we decided that the Plan does not have to pay for urgent care services provided on August 11, 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 enrollee will require acute level
hospital care for a long-term basis which is best provided in an LTACH. The Plan denied your request. The
Plan says all services that would be provided in the LTACH are being provided already in the current acute
care setting.
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 is currently undergoing treatment at an ACH following a diverting
colostomy. The enrollee is receiving wound care, antibiotics, supplemental nutrition and his routine
hemodialysis. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT). You asked the Plan to pre-approve 5 fractions of SBRT. You say that the services 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 5 fractions of SBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the enrollee has had reduction in the lung tumor, the adrenal lesion has grown during systemic treatment with Keytruda. Therefore, the NCCN recommendation for SBRT does not apply to the enrollee's situation. Instead, the recommendation on the same page in the NCCN Guideline, states for palliative radiation for advance or metastatic NSCLC, 3D-CRT is acceptable. The office visit note of June 5, 2020 states the option of standard radiation was discussed. Therefore, the requested therapy exceeds the enrollee's medical need. The requested treatment is not medically reasonable and 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 5 fractions of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 22, 2019 to December 8, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care. 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 the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 22, 2019 to December 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen One G3 portable oxygen concentrator purchased on September 11, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you need the device and it falls under your durable medical equipment 20% coinsurance. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Inogen One G3 portable oxygen concentrator purchased on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metrogel Topical.
You asked the Plan to pre-approve Metrogel Topical. You say that the enrollee needs this drug. The Plan denied your request. The Plan says this is a Part D drug.
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 Metrogel Topical.
Benefits for Metrogel Topical may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services
You asked the Plan to pre-approve the continued SNF services. You say that the enrollee has been participating in therapy services and is making substantial progress. The Plan denied your request. The Plan says the enrollee has been getting physical therapy but is not getting better. The Plan also says the enrollee could have the care needed at an alternate level of care.
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 continued SNF services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the observation stay provided from October 26, 2019 to October 27, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you received the $35 copayment even though it is a doctor's charge related to an emergency room visit. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit the 2019 Evidence of Coverage or the Explanation of Benefits to support the observation charge. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the observation stay provided from October 26, 2019 to October 27, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fully-electric hospital bed. You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this equipment is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully-electric hospital bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for myelography via lumbar injection and a CT scan provided on January 31, 2020.
You asked the Plan to waive the copayments for myelography via lumbar injection and a CT scan. You say that you disagree with 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 $250 copayment for outpatient hospital services. Your contract with the Plan also clearly says that enrollees must pay a $150 copayment for diagnostic radiology. You received myelography via lumbar injection on January 31, 2020. Myelography via lumbar injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You received a CT scan on January 31, 2020. Therefore, you are responsible to pay the $150 copayment. The total amount you owe is: $400. You have been asked to pay the total copayment amount of $400 for myelography via lumbar injection and a CT scan. Myelography via lumbar injection and falls within the outpatient hospital services benefit category. A CT scan 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 myelography via lumbar injection and a CT scan provided on January 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from July 8, 2019 to December 10, 2019.
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 are not covered. The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from July 8, 2019 to December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement
graft (D4263), and occlusal adjustment (D9952) provided on November 19, 2019.
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft, and occlusal adjustment.
You say that you were referred to this provider by your dentist. You also say that you received a preauthorization
for the services. The Plan denied your request. The Plan says these services are not covered
benefits.
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
guided tissue regeneration (D4266), bone replacement graft (D4263), and occlusal adjustment (D9952)
provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 15, 2019.
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 procedure code G0481 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. 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 pay for the drug testing rendered on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intermittent urinary catheter; coude
(curved) tip, with or without coating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each (A4352)
provided from March 7, 2019 through December 9, 2019 from an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that in four (4) years you have never been
billed for this service. The Plan denied your request. The Plan says the claims were 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 show that you received urinary catheters March 7, 2019 through December 9, 2019 from an
in-network provider. You are asked to pay 20% coinsurance for the DME. Your EOC states, enrollees must pay
20% coinsurance for in-network DME. 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 coinsurance for
intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, silicone elastomeric,
or hydrophilic, etc.), each (A4352) provided from March 7, 2019 through December 9, 2019 from an innetwork
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 it is felt that this level of care is most appropriate for the enrollee's condition. The Plan denied your request. The Plan says the enrollee would not benefit from three hours of daily intensive rehab services.
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 enrollee presented to the acute hospital on 05/30/2020 with a left femoral neck fracture after a fall. He underwent surgery on 06/01/2020 with a left total hip arthroplasty. His surgery was without any major reported complication. He is reported to be pleasantly confused, weak and deconditioned and he is working with physical and occupational therapy. He is walking just a few feet with two-person assistance with a rolling walker and he is maximum assist for transfers and activities of daily living. Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require skilled physical therapy and occupational therapy but does not require treatment in 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee needs to stay in the hospital until he is better.
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. The patient
is currently undergoing treatment at an acute care hospital for complications following a recent motor vehicle
collision (MVC). The enrollee required chest tubes, surgery, intubation and ventilation for loculated pleural
effusions. The enrollee has been extubated and had his chest tubes removed. There is no evidence that the
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at
the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged
to a lower level of care for any ongoing LTC needs. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on February 11, 2020.
You asked the Plan to pay for the services. 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 for the medical services provided to the enrollee by an out-of-network provider
on February 11, 2020.