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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 14, 2020.
You asked the Plan to waive the copayment for an ultrasound. 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 $160 copayment for ultrasounds. You have been asked to pay the allowed amount of $102.79, which is less than the $160 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 19, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would not owe a copayment for follow-up visits. 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 $45 copayment for specialist visits. You had a specialist visit on November 19, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 29, 2020.
You asked the Plan to pay for the laboratory 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 laboratory services. 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 laboratory services provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultrasound guided peripheral nerve blocks with combined electro-analgesia.
You asked the Plan to pre-approve the ultrasound guided peripheral nerve blocks with combined electro-analgesia. You say that you would like reconsideration because the purpose of the treatments is to stop and reduce the effects of the neuropathy. The Plan denied your request. The Plan says treatment protocols utilizing multiple injections per day on multiple days per week, for peripheral neuropathies is not medically necessary.
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 the ultrasound guided peripheral nerve blocks with combined electro-analgesia. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested nerve block injection, with ultrasound and Marcaine, has not been proven in double blind clinical trials to be effective and thus the request should be denied because it is not the standard 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 the ultrasound guided peripheral nerve blocks with combined electro-analgesia have not been met. Therefore, we decided that the Plan does not have to pre-approve ultrasound guided peripheral nerve blocks with combined electro-analgesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildups (D2950 x2) provided on July 10, 2020.
You asked the Plan to pay for core buildups. You say that you feel that the service was an emergency, and you want the plan to pay for it. The Plan denied your request. The Plan says this service is not a covered benefit.
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 core buildups (D2950 x2) provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for eyeglasses received on November 27, 2020.
You asked the Plan to fully pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim processed correctly.
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 eyeglasses with up to a $300 benefit. We looked at the file and the Plan's rules. The file shows that the total cost for the glasses was $491. The plan paid $300 of this cost. You are responsible for the remainder ($191). Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to fully pay for eyeglasses received on November 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance ride provided on October 28, 2020.
You asked the Plan to waive the cost share for the ambulance ride. You say that the credit union called the ambulance when your husband could have taken you to the hospital. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible that applies towards an ambulance ride and a $100 copayment for each one-way Medicare-covered ambulance transport after your yearly deductible is met. The ambulance ride you asked the Plan to waive the cost share for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards an ambulance ride and a $100 copayment for each one-way Medicare-covered ambulance transport after your yearly deductible is met. The medical record shows you received ambulance services. See chart below.
This cost sharing is a contractual obligation that had not been met at the time the ambulance ride was received
on October 28, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the
ambulance ride provided on October 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 20, 2020, to October 2, 2020.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you are not a Medicare certified provider.
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 who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 20, 2020, to October 2, 2020.
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 a LTACH admission is medically 
necessary for the enrollee. 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 the enrollee was admitted to the current acute care hospital with abdominal pain, 
diarrhea as well as hypoxia related to COVID-19. He required intubation, a trach, and percutaneous endoscopic 
gastrostomy placement. He was diagnosed with pneumothorax requiring chest tube placement. He recently 
failed two weaning trials off sedation. He requires Levophed and Midazolam, and was deemed a poor 
prognosis in recent notes. The enrollee appears to be unstable and does not appear to be able to wean. He 
requires short-term additional acute care services that can safely be received at the current facility until an 
appropriate longer-term location and level of care may be determined. The enrollee does not require services at 
the LTACH that are not already available and covered at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. This request 
for LTACH care will be considered not medically necessary at this time. Transfer may be considered soon 
when 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 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 pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing 
facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of continued inpatient skilled nursing facility care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that 
continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that 
at the time of admission, you required skilled rehabilitation services to improve function due to weakness and 
deconditioning. Skilled nursing needs included care for a feeding tube and wound care. As of April 1, 2021, 
you did not require any skilled nursing or rehabilitation services on a daily basis. You were not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. You did not require skilled therapy to establish a safe 
and effective maintenance program. As a practical matter, you did not require any skilled services on an 
inpatient basis, at a SNF level of care. You did not have any parental medications, daily complex wound care 
or complications with a feeding tube that provides nutrition. You received skilled care and improved, however 
your function had plateaued and you did not require any further inpatient skilled rehabilitation services.  
Additionally, your function was at or near your prior level of function and you could be discharged to a lower 
level of care for further services. As of April 1, 2021, you required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
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 this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
recurrent respiratory failure. The enrollee was transiently intubated/ventilated, but has since been extubated and 
is no longer on a ventilator. 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 acute care hospital until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 for this enrollee to 
regain maximum function and eventually return home. The Plan denied your request. The Plan says the request 
for IRF care is not medically necessary and the enrollee is able to receive safe and adequate care in a Skilled 
Nursing Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. Based 
on the documentation provided, it is the opinion of our physician reviewer that the Health Plan's denial should 
be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee 
is not shown to be able to perform fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care, such as a Skilled Nursing Facility, 
Long-Term Care, or Sub Acute Rehab. 
 
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 pay for inpatient hospital services. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the submitted claim does not have the 
required present on admission indicators. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, inpatient claims require a present on 
admission indicator unless the diagnoses are exempt. In this case, none of the diagnoses on the claim are 
exempt, therefore a present on admission indicator is required. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services.
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 a delay for Inpatient Rehab will jeopardize your chance for a full recovery. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. 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 were admitted for congestive heart failure. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170). 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the Plan?s rules. Based on this information, we 
decided that the Plan?s rules for coverage of routine transportation have not been met. Specifically, your 
request submitted to the Plan was for a total of 203 miles for each trip. However, the Plan contract provides 
coverage for 50 miles of driving distance only for each trip. Your request exceeds the allowable transportation 
benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine mileage, per trip 
(A0170).