Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 4, 2019 through January 5, 2019.You asked the Plan to pay forinpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity.Therefore, we decided that the Plan has to pay forinpatient hospital care provided to the enrollee from January 4, 2019 through January 5, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTheophylline ER.You asked the Plan to pre-approveTheophylline ER. The Plan denied your request. The Plan says this is not covered under the enrollee's medical plan.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-approveTheophylline ER
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from July 3, 2019 through July 5, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you believe you were incorrectly charged for two copayments.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received inpatient hospital care from July 3, 2019 through July 5, 2019 provided by an in-network provider. You were asked to pay a $350 copayment per day from July 3, 2019 through July 4, 2019, days 1-2 of your inpatient hospital care. You were discharged on July 5, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5. 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 forinpatient hospital care from July 3, 2019 through July 5, 2019 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from March 29, 2019 through April 8, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. On the Medicare web site, CMS.gov, the file FY 2019 Present On Admission POA Exempt List, POA exempt codes 2019, the POA exempt codes Z79.01, Z88.8 AND Z95.0 are present on the list.Diagnosis codes Z79.01, Z88.8 and Z95.0 are on the exempt from reporting list Diagnosis codes Z79.01, Z88.8 and Z95.0 are on the exempt from reporting list and were billed on the UB-04 with POA indicator 1. Therefore,we find the Medicare rule for payment of this March 29, 2019 through April 08, 2019, claim has not been met and the plan could not pay this claim as billed. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. You can find the above guidelines on the Medicare web site, https://www.cms.gov.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from March 29, 2019 through April 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Butrans Dis 15mcg/hr.You asked the Plan to pre-approve Butrans Dis 15mcg/hr. You say that the enrollee needs the brand name due to issues with the generic.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.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-approveButrans Dis 15mcg/hr.Benefits for Butrans Dis 15mcg/hrmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
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 clinical documentation supports the need for IRF care. The Plan denied your request. The Plan says the records do not indicate that the enrollee requires IRF care. The plan says that the enrollee can safely receive the needed services in another 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. Our physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight in an IRF. The enrollee may benefit from additional physical therapy and occupational therapy, but the documentation does not support that her functional level requires this on an intensive rehabilitation therapy program level that is provided 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF carefrom July 5, 2019 through July 24, 2019.You asked the Plan to waive the copayment forSNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).Review of the file shows that you were admitted on July 5, 2019 and were discharged on July 24, 2019. There were no copay charges for the first 20 days (June 20, 2019 through June 27, 2019 and July 5, 2019 through July 17, 2019). You were asked to pay a $167.50 copayment per day for SNF services provided on July 18, 2018, your 21st day of SNF care through July 23, 2019. You were discharged on July 24, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $167.50 copayment required for days 21-100. 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 SNF care from July 5, 2019 through July 24, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided on August 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the billed services were misrepresented.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 contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided on August 23, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 20, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on September 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve personal assistant services.You asked the Planto pre-approve the services. You say that this is medically necessary, as you had life support called twice during the last hospital visit.The Plandenied your request. The Plan says you do not meet the minimum impairment score of 24 to qualify for this service at this time.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medicallynecessary 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you report that you need assistance with cooking and going to his doctor's appointments. You are currently in PT for weakness. He does not require assist with ADLs. You were evaluated during an assessment for the need for skilled services. You did not meet the minimum required score for needing skilled services. Based on available records, you do not meet criteria for coverage of request for personal assistant services. You do not currently have any skilled needs. You are able to complete ADLs, mobility, and transfer without assistance. You do not meet the minimum scoring assessment for services. The records do not support the requested services are medically necessary. This request exceeds your 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepersonal assistant services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the PSA laboratory testing provided on September 4, 2019.You asked the Plan to waive the copayment for the PSA laboratory testing. You say that there should not be a copayment because prostate cancer screenings are covered. 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 $20 copayment for each covered lab service. You have been asked to pay a $20 copayment for the PSA laboratory testing. The PSA laboratory testing falls within the "Outpatient diagnostic tests and therapeutic supplies and services" benefit category. The record shows a diagnosis of benign prostatic hyperplasia which makes the lab test diagnostic in nature.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 PSA laboratory testing provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT Code K0815).You asked the Plan to pre-approvethe power wheelchair. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. The power wheelchair is being requested for use outside the home only. The physician clearly states the power wheelchair is for use only outside the home and that you use the manual wheelchair to move around the home. The Medicare rules do not cover power wheelchair only for use outside the home.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT Code K0815)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on August 12, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that you did not go to urgent care on August 12, 2019. You say you only went on August 8, 2019 and August 19, 2019. The Plan denied your request. The Plan says you have been charged thecorrect 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 $30 copayment for each visit in a contracted Urgent Care Center or walk-in clinic. You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within "Urgently needed services" benefit category. The medical record shows you were seen for a follow-up on August 12, 2019.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 urgent care visit provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission criteria.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on September 17, 2019.You asked the Plan to pay for the vaccine. You say that you were told this was covered.The Plan denied your request. The Plan says you were told after the first vaccine that this is not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on September 17, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 care can be received in another 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. Our physician reviewer found 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 PT and OT 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 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 for oxygen concentrator (CPT Code E1390) provided to the enrollee on September 1, 2019.You asked the Plan to pay forthe oxygen concentrator. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Review of the available clinical case notes andrecords presented for an appeal of skilled nursing facility services has been completed.  The oxygen concentrator rental service is not authorized because it is a part-A benefit for skilled nursing facility (SNF) admissions and are included in the facility PPS payment. The facility received Medicare part-A skilled nursing facility payment and is responsible to provide all services and pay any and all vendors. After reassessing the entire situation, the result is that the initial denial is upheld and the service is not authorized.Therefore, we decided that the Plan does not have to pay foroxygen concentrator (CPT Code E1390) provided to the enrollee on September 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain 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 Botox. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of primary focal hyperhidrosis of the soles of the feet. The enrollee complained of sweating that is episodic and severe in severity. Botox has been approved by the FDA for the treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical therapy. The enrollee does not meet criteria for the requested Botox injection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on March 25, 2019You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under OriginalMedicare.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. The member was enrolled in hospice from August 1, 2018 through March 26, 2019.Therefore, we decided that thePlan does not have to pay forthe services provided to the enrollee on March 25, 2019