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

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve the additional mileage. You say that you have to see your old pain
management doctor who is 63 miles away. The Plan denied your request. The Plan says this exceeds the benefit
limit.
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. The Plan covers routine transportation when each one-way trip does not exceed 50 miles one-way.
We looked at your request, the records in the case file, and the rules. The requested trip is 63 miles away, oneway,
which exceeds the benefit. Based on this information, we decided that the Plan's rules for coverage of
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve
additional mileage.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep study device to be provided by a non-
Medicare supplier.
You asked the Plan to pre-approve the request home sleep study device. You say that you are asking for this
coverage to be approved under your integration Medicaid plan which you say is not restricted to only
Medicare providers. The Plan denied your request. The Plan says this is requested from a non-Medicare
provider and cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that no payment can be made to a provider not
enrolled in the Medicare program.
This provider does not accept insurance and is not enrolled in Medicare. Therefore, we decided that the Plan
does not have to pre-approve a home sleep study device to be provided by a non-Medicare supplier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that you do not have ample time to verify eligibility and process authorization.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 forthe medical services provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe presumptive screening drug testing and the definitive testing for 1-7 drug classes provided on September 25, 2019.You asked the Planto pay forthe presumptive and definitive drug testing. You say that this was rendered due to the order of the treating physician for further treatment and management of care.The Plandenied your request. The Plansaysthatthere are no valid orders submitted since the orders do not document exactly what drugs are to be tested.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider.In this case, there is an order for both a screening (presumptive) and screening with validity (definitive) testing panel. The progress note clearly documents the intent for the testing to be performed and includes thecodes, namely G0480 which is for the definitive testing of 1-7 drug classes. There is no evidence that the lab provided services that were not duly ordered by the treating provider.Therefore, we decided that the Planhas to pay forthe presumptive screening drug testing and the definitive testing for 1-7 drug classes provided on September 25, 2019.If the Plandoes 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/orsend 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided on January 16, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the inpatient 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 mustdisclose 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 $325 copayment for inpatient hospital care. The medical records show that you had an inpatient hospital stay on January 16, 2020. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exams and therapy/treatment provided from May 16, 2018 to December 20, 2018.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until January 10, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decidedthat the Plan does not have to pay forthe eye exams and therapy/treatment provided from May 16, 2018 to December 20, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health care services provided to the enrollee from October 16, 2019 to October 30, 2019.You asked the Planto pay forthe services. You say that thisshould be paid for.The Plandenied your request. The Plansaysthe service was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the denied codes are not supported in the medical record. Specifically, a corrected claim containing the Federal Information Processing Standards (FIPs) code must be submitted. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forhome health care services provided to the enrollee from October 16, 2019 to October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray provided on December 18, 2019.You asked the Plan to pay forthe intraoral periapical x-rays. You say that the provider assured you that a set of bitewing x-rays includes three different slides taken. You also say that your insurance company asked your provider to bill each x-ray separately.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, periapical x-rays are not among those coveredunder this benefit.The record shows that you received bitewing x-rays at this visit and were appropriately charged the 50% coinsurance. Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 18, 2019by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that you cannot turn away specimens for lab testing as the results are crucial to the enrollee's care with the ordering physician.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 forthe medical services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forpsychotherapy provided on January 3, 2020 and January 7, 2020.You asked the Plan to waive the copayment forpsychotherapy. You say that you were not aware your copayment had changed. You say that your copayment should be $20 for each visit.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per individual or group therapy visit.You have been asked to pay a $40 copayment for each psychotherapy visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). Psychotherapy falls within the "Outpatient mental health care" 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 forpsychotherapy provided on January 3, 2020 and January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 nota 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 forthe medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided thatthe Plan does not have to waive the copayment forthe CT scan provided on January 14, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you would like the Plan to pay full price and for this to be covered again because you cannot afford this amount. 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 $175 copayment for each Medicare-covered advanced radiology service. You have been asked to pay a $175 copayment for the CT scan. The 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 copayment forthe CT scan provided on January 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided on November 10, 2018.You asked the Plan to pay forthe 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 was admitted to Hospice services on November 10, 2018. The Plan also says that while on Hospice, Skilled Nursing Facility level services are not a covered benefit.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided on November 10, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says acupuncture services are not a covered benefit under your contractual policy for your condition.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the case file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does not indicate that you have requested acupuncture services for the diagnosis and treatment of chronic low back pain (CLBP). Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit
You asked the Plan to issue reimbursement for the office visit. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not
a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to issue reimbursement for the office visit
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve continued admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be met in a lower level of care with services such as 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 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 onMedicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services that are provided at the IRF. Specifically, the enrollee is not shown to require 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 (ex. SNF/SAR, LTC).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 Plandoes not haveto pre-approvecontinued admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided May 25, 2019 through June 7, 2019 and June 14, 2019 to June 23, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for SNF services.The Plandenied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs.The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services havenot been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided May 25, 2019 through June 7, 2019 and June 14, 2019 to June 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea manual wheelchair for the enrollee.You asked the Plan to pre-approvea manual wheelchair. The Plan denied your request. The Plan says it is unclear how the wheelchair will help the enrollee be more independent with activities of daily living.The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain medical indications.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 a manual wheelchair. Our physician reviewer found that the enrollee is ambulating greater than household distances during the 6-minute walk test. A front wheeled walker is also being requested, which does not confirm thatany mobility deficit cannot be helped with use of a standard mobility aide. The enrollee does not meet criteria for a manual wheelchair.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approvea manual wheelchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from October 29, 2019 to October 31, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says thatthe enrollee could have been treated at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee was admitted on October 26, 2019 forsevere right wrist pain and concern for septic joint and intractable pain.  He was found to have hydronephrosis. His condition stabilized and improved with medical treatment and he was discharged October 31, 2019 when considered medically stable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from October 29, 2019 to October 31, 2019.