Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing services provided from June 10, 2020, to June 30, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the enrollee's skilled nursing benefit has been exceeded.
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 provide records showing the enrollee has exhausted their 100 day Skilled Nursing Facility (SNF) care benefit. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the skilled nursing services provided from June 10, 2020, to June 30, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fortherapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96372) and Injection, mepolizumab (J2182) provided march 10, 2020.You asked the Plan to waive the coinsurance forthe injection services. You say that you have been taking this shot for over a year and never had to pay anything for it. You never would have agreed to obtain this policy if they agent had been honest with you.The Plan denied your request. The Plan says this claim was processed and the correct cost shares was applied per the Evidence of Coverage.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 20% coinsurance for Medicare Part B covered drugs.You have been asked to pay $585.80 for the injection services. The injection services fall within the Medicare Part B prescription drugs 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 coinsurance fortherapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96372) and Injection, mepolizumab (J2182) provided march 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation and preventive procedure provided on September 24, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation and preventive procedure.You say that you contacted the Plan multiple times and were advised that the extraction procedure would be covered.The Plan denied your request. The Plan says these services are not covered. The Plan also says that in-network providers are receiving a monthly reimbursement for unspecified preventive procedures, and additional reimbursement cannot be issued.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. The Plan says that when you contacted the Plan you were advised that your dental plan was code specific and covered simple extractions (D7140) and surgical extractions. The Plan also says that you were never told that coverage would be provided for a limited oral evaluation or unspecified preventive procedures.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation and preventive procedure provided on September 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance mileage traveled beyond the closest appropriate facility (A0888) provided on August 5, 2020.You asked the Plan to pay forambulance mileage traveled beyond the closes appropriate facility. You say that the service was medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance mileagetraveled beyond the closes appropriate facility have not been met. Specifically, you received an emergency transport beyond the closed appropriate facility. The extra mileage to get to the requested facility is not a covered benefit.Therefore, we decided that the Plan does not have to pay forambulance mileage traveled beyond the closest appropriate facility (A0888) provided on August 5, 2020
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee qualifies for IRF care. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at home with home health care, or in a long-term care setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 was admitted for cervical laminectomy. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance forkeratoplasty provided on March 5, 2020.You asked the Plan to waive the deductible and coinsurance forkeratoplasty. You say that you were told that the provider was in-network and the surgery would be fully covered.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. Your contract with the Plan says that there is a $500 deductible. Your contract with the Plan also clearly says that after the $500 deductible has been met, enrollee's must pay 35% coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.You received keratoplasty from an out-of-network provider, on March 5, 2020. Therefore, you are responsible to pay your share of the out-of-network services. The record shows that you had paid $0 toward the $500 deducible prior to receiving the services. Therefore, you are responsible to pay the $500 deductible. Now that the $500 deductible has been met, you are also responsible to pay 35% coinsurance on the difference between the allowed amount and the deductible amount. $13,441.36 (allowed amount) -$500 (deductible) = $12,941.36 and 35% of that is $4,529.48. The total amount you owe is: $4,529.48 + $500 = $5,029.48. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time keratoplasty was received on March 5, 2020.Therefore, we decided that the Plan does not have to waive the deductible and coinsurance forkeratoplasty provided on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the service is medically necessary.The Plan denied your request. The Plan says you donot require daily complex nursing care or daily skilled therapies.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 there are no identifiable skilled nursing service needs and you donot require skilled nursing or therapy services on a daily 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 SNF care have not been met. Specifically, you donot meetseverity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review thecase 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left above the knee amputation from 12/15/2020 to 12/24/2020. The enrollee was transferred to skilled nursing facility from 12/24/2020 to 1/29/2021 and has now been discharged to home with home health physical and occupational therapy. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicarerules. 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 wascorrect 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 was admitted for seizure andpneumonia. The enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on October 27, 2019, by an
out-of-network provider.
You asked the Plan to pay for the radiology services. You say that you would like the Plan to pay this claim as
you cannot afford it. The Plan denied your request. The Plan says you did not request prior authorization for the
non-emergent 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 had network providers
available who could have provided 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 radiology services provided on October 27, 2019, by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 21, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe OON medical services. You say that the enrollee has been a patient of the out of network provider for 20 years for Schizoaffective disorder; a chronic mental health condition. You say that a change in the enrollee's care would have disrupted his balance. You say that you were unaware of the need for a referral when the enrollee's coverage changed this year.The Plan denied your request. The Plan says the rendering provider is a non-participating provider and there are no prior authorizations to see this provider on file. The Plan says that the enrollee's family was made aware on June 25, 2019 and on February 24, 2020, that the enrollee needs a referral from his primary care physician 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 had network providers available who could have provided 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 September 21, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PRALUENT.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 PRALUENT.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation service (A0429-QL) provided on August 23, 2020.
You asked the Plan to pay for this service. 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 payable as it was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for the ambulance transportation service (A0429-QL) provided on August 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and prefabricated post and core in addition to crown provided on October 2, 2019. You asked the Plan to pay for the crown and prefabricated post and core. You say that the provider did not
submit the original claim on time under the belief that the service would not be covered. The Plan denied your request. The Plan says the provider had until October 2, 2020, to submit the claim. The Plan also says that the claim was not received until October 23, 2020, which was after the deadline to submit. 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 the crown and prefabricated post and core was not filed until October 5, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the crown and prefabricated post and core in addition to crown provided on October 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered from October 9, 2020 to October 11, 2020.
You asked the Plan to waive the copayment for these services. You say that you had chest pain and trouble breathing. The Plan denied your request. The Plan says the copayment was 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 $90 copayment for in-network emergency room services.
Review of the file shows that you received ER services from October 9, 2020 to October 11, 2020. You have been asked to pay a $90 copayment for these services. These services fall within the in-network emergency room services 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 the emergency room (ER) services rendered from October 9, 2020 to October 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
You asked the Plan to pre-approve the SCS trial. You say that the enrollee should be allowed this treatment for her condition. The Plan denied your request. The Plan says there is no evidence that surgery has been ruled out in this case nor that maximal medication management has been provided.
The Plan follows Medicare rules. Medicare rules say that SCS placement may be covered when reasonable and necessary based on the above noted rules. 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 SCS trial. Our reviewer says that the requested SCS trial is not reasonable and necessary based on Medicare rules. Our physician reviewer found the enrollee is a female with chronic neck pain and cervical radiculopathy and diabetic neuropathy. She is taking gabapentin, Tizanidine and medical cannabis for pain. She has not had surgical treatment. She has not had maximal medical management. There is not adequate documentation of any form of neurosurgical evaluation that indicates that she not a surgical candidate. She has no other evidence-based indication for a SCS trial. The requested procedure is not medically reasonable or 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 the SCS trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.