Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump provided from February 28, 2019 to March 1, 2019.
You asked the Plan to pay for the ambulatory infusion pump. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 E0781 is Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient. We find that CPT code E0781 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery. Based on this information, we decided that Medicare rules for coverage of the ambulatory infusion pump have not been met. Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump provided from February 28, 2019 to March 1, 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 enrollee is with closed fracture left hip requiring IM nailing left femur on 02/01/2020. He had a recent admission to hospital for diverticular bleed and was discharged to subacute rehab. Prior to that admission the enrollee had been hospitalized due to epidural abscess for which he has a PICC line and is receiving antibiotics (ampicillin). At the subacute rehab he tried to get up to go to the bathroom using another patient's walker and fell. The enrollee's prior level of function was independent with mobility using walker/cane and independent with activities of daily living. He lives with adult child(ren) in a 2 story house with 3 steps to enter and first floor set up. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.
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 ophthalmology services (76514, 92004, 92020, 92083, 92132, 92133, 92286) provided on August 27, 2019 by out of network provider.
You asked the Plan to pay for ophthalmology services. You say that you are appealing the denial of payment for ophthalmology services rendered by non-participating provider on date of service August 27, 2019. The provider's office told you that they accepted your insurance and that they also accepted your copayment. The Plan denied your request. The Plan says the service received is not a covered benefit under your plan. You have an HMO plan and must see an in-network provider. You contacted the plan and were told services received by an out-of-network provider would not be covered by the plan. You self-referred to an out-of-network provider. The services are not covered by the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for ophthalmology services (76514, 92004, 92020, 92083, 92132, 92133, 92286) provided on August 27, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician visits provided on August 11, 2019, August 12, 2019 and August 14, 2019.
You asked the Plan to waive the deductible for physician visits. You say that the doctors and hospital are double dipping. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $1,364 per plan year for most Part A in-network and out-of-network services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Physician services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category "Physician/Practitioner Services, Including Doctor's Office Visits". The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,364 deductible applies to physician services. The allowed amount for the physician visits is $239.65. Therefore, $239.65 was applied to your $1,364 deductible.
This cost sharing is a contractual obligation that had not been met at the time physician visits were received on August 11, 2019 to August 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the physician visits provided on August 11, 2019, August 12, 2019 and August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient hospital stay provided from August 11, 2019 to August 15, 2019.
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that you believe the doctors and hospital are 'double-dipping.' The Plan denied your request. The Plan says you have been charged 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 $1,364 deductible that applies towards in-network inpatient hospital stays.
The inpatient hospital stay you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,364 deductible that applies towards in-network inpatient hospital stays. The allowed amount is $5,872.29. You have only been asked to pay $607.68 because this is the amount that meets your $1,364 deductible. The record shows $756.32 had already been applied to your deductible. ($1,364 - $756.32 = $607.68).
This cost sharing is a contractual obligation that had not been met at the time the inpatient hospital stay was received on August 11, 2019 to August 15, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient hospital stay provided from August 11, 2019 to August 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services provided on September 21, 2019 and on September 28, 2019.
You asked the Plan to waive the copayment for observation services. You say that you should not be charged for 2 hospital visits since one visit was not successful. The Plan denied your request. The Plan says outpatient hospital services for observation have a $250 copayment.
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 for observation. You have been asked to pay a $250 copayment for observation services. These services falls within the outpatient hospital services for observation benefit category ($250 x 2 = $500). 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 observation services provided on September 21, 2019 and on September 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 27, 2019 by an out-of-
network provider.
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 were rendered by a non-participating provider without 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 27, 2019
by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that it is not safe for you to go home. The Plan denied your request. The Plan says your needs are custodial.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. Your needs are custodial in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services and an x-ray provided on August 28, 2019 by out of network provider.
You asked the Plan to pay for podiatry services and an x-ray. You say that you were never notified that your visit would not be covered. You say that you did not find out until you received your EOB. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services and an x-ray provided on August 28, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the wound care provided on June 7, 2019.
You asked the Plan to reduce the copayment for the wound care. You say that you received the services at a hospital which is a Tier 2 facility and should only be responsible for a $10 copayment for services in a Tier 2 primary care doctor's office. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for wound care at an outpatient hospital.
You have been asked to pay a $68.22 for the wound care. The wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you received the wound care at an outpatient 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 reduce the copayment for the wound care provided on June 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on May 29, 2019.
You asked the Plan to pay for the outpatient hospital 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 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 outpatient hospital services provided on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81321, 81314, 81310, 81272, 81311, 81201, and 81173 provided on July 31, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81321, 81314, 81310, 81272, 81311, 81201, and 81173 provided on July 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs therapy. 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 presented to the emergency room on January 21, 2020 and was admitted for pneumonia. The physical therapy note dated February 4, 2020 states that she was unable to participate in goal setting and needed total assist with bed mobility due to no trunk control. As of February 10, 2020 she is able to follow simple one-step commands and was still dependent with bed mobility. 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. 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 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that they did not receive documentation with information meeting step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Zoledronic acid or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 1, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician's services provided on April 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and an additional periapical x-ray (D0230) provided on August 26, 2019.
You asked the Plan to pay for the dental services. You say that you do not think you should have to be responsible for the charges. You say that the provider knows what is covered under your insurance. You also say that you were not advised what type of x-ray you received. The Plan denied your request. The Plan says periapical x-rays are not covered services.
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 periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and an additional periapical x-ray (D0230) provided on August 26, 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 LTACH is needed in this case. The Plan denied your request. The Plan says no need for any services at an LTACH.
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 for CHF. The enrollee was briefly intubated/ventilated, but is no longer intubated/ventilated. 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.