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

We decided that the Plan does not have to pay for the skilled nursing services provided from November 5, 2019
to December 4, 2019.
You asked the Plan to pay for the 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's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 5, 2019 to December 4,
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic imaging provided on
January 22, 2020.
You asked the Plan to waive the copayment for the ophthalmic imaging. You say that you had a serious
reaction to a shot. You say that you shouldn't have to pay a copayment for a follow up. The Plan denied your
request. The Plan says the copayment 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 $10 per
day for Medicare-covered tests.
You have been asked to pay a $10 copayment for the ophthalmic imaging. The ophthalmic imaging falls within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in
the contract which indicates a copayment would be waived for services performed as a follow-up. 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 ophthalmic imaging provided on January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says that the
medical records submitted do not support the medical necessity required to approve the request for skilled
nursing level of care. The Plan also says that the enrollee can be cared for at a lower level of care.
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 the SNF admission. Our reviewer says
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did
not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve the SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 19,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you say you should not be charged
two copayments for one office visit. 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 $5
copayment for PCP office visits.
You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows you are being
charged one copayment for the destruction of a premalignant lesion, in addition to the routine physical exam.
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 office visit provided on November 19, 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 requested LTACH care is considered
medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested
LTACH care is not considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted to acute care on 4/19/20 with Non-ST-elevation
myocardial infarction (NSTEMI). Due to severity of coronary artery disease she was scheduled for coronary
artery bypass graft on 4/22/20.
Based on the documentation provided for review, the enrollee does not have any particular issue that would
necessitate LTACH level of care. The recommended level of care from occupational therapy was SNF. No
specific wound care or therapy that would require LTACH level is evident on review of the case.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tandem T6 replacement insulin pump.
You asked the Plan to pre-approve the replacement insulin pump. You say that the enrollee is a type II diabetic
and needs the pump. You say that the enrollee also has diabetic macular edema. You say that, despite the
current pump being under warranty until 2022, the enrollee does not trust this pump and wants to have it
replaced. The Plan denied your request. The Plan says the criteria for coverage of a replacement insulin pump
has not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. Medicare rules also say that the useful lifetime of a DME must be no less than 5
years, and that Medicare will cover repair costs.
The file shows that you have a Medtronic insulin pump. A Medtronic insulin pump serves the same purpose as
the replacement insulin pump you are requesting. The records show that the insulin pump the enrollee currently
has is under warranty and issues with this device can be resolved. Therefore, we decided that the Plan does not
have to pre-approve a Tandem T6 replacement insulin pump.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 31, 2019.
You asked the Plan to pay for the nurse practitioner 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 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 nurse practitioner services provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle/foot orthosis LT, RT (L1971x2) provided January 10,
2020.
You asked the Plan to pay for the orthoses. You say that the supporting documentation will show that you
dispensed medically necessary supplies pursuant to physician orders, which were received by the enrollee. The
Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that
the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the provided records do not pertain to the ordering of the ankle/foot orthoses. There is no
documentation of a chief complaint related to the enrollee's ankles, no evidence of recent ankle injury or
surgery, no documentation of an ankle exam and no evidence of joint laxity or instability. As such, the
provided ankle/foot orthoses are not shown to have been medically necessary or reasonable
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 orthoses have not been met. Therefore, we decided that the Plan does not
have to pay for ankle/foot orthosis LT, RT (L1971x2) provided January 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the nursing home was only given Medicaid as the enrollee's insurance and you were not aware that she had Medicare until your claims were denied. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered
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 subsequent nursing facility care (99308) provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider is employed by the hospital to serve
medically necessary functions. The Plan denied your request. The Plan says prior authorization is required for
out-of-network providers.
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 for the medical services provided on January 7, 2019 by an out of network
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is a lack of skilled needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 medically reasonable or necessary. Our physician reviewer found the medical
records do not show that skilled nursing services are required to effectively provide treatment, care, and/or
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to
maintain the enrollee's condition and/or prevent deterioration.
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 Plan does not
have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 30, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says they did not approve these services. The Plan says
that prior authorization is required for these out-of-network 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 an office visit provided on December 30, 2019 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for below knee, molded socket, shin, sach foot, endoskeletal
system (L5301) test socket below knee (L5620) below knee acrylic socket (L5629) socket insert with locking
mechanism (L5673) below knee / above knee suspension locking mechanism (L5671) below knee total contact
(L5637) below knee, suspension/sealing sleeve (L5685) custom shaped protective cover below knee (L5704)
and endoskeletal system, below knee, alignable system (L5910) endoskeletal system, below knee, ultra-light
material (L5940) flexible keel foot (5972) prosthetic sheath, below knee (L8400) prosthetic sock, multiple ply,
below knee (L8420) prosthetic sock, single ply, fitting, below knee (L8470) provided January 7, 2020.
You asked the Plan to pay for the orthoses. You say that the permanent prosthesis is medically necessary to
allow him to carry his activity of daily living. The Plan denied your request. The Plan says there is insufficient
documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery or an
itemized shipping/billing invoice for the supplies provided in this case. Therefore, we decided that the Plan
does not have to pay for below knee, molded socket, shin, sach foot, endoskeletal system (L5301) test socket
below knee (L5620) below knee acrylic socket (L5629) socket insert with locking mechanism (L5673) below
knee / above knee suspension locking mechanism (L5671) below knee total contact (L5637) below knee,
suspension/sealing sleeve (L5685) custom shaped protective cover below knee (L5704) and endoskeletal
system, below knee, alignable system (L5910) endoskeletal system, below knee, ultra-light material (L5940)
flexible keel foot (5972) prosthetic sheath, below knee (L8400) prosthetic sock, multiple ply, below knee
(L8420) prosthetic sock, single ply, fitting, below knee (L8470) provided January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the a chest x-ray (71045) provided on December 1, 2019.
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 a chest x-ray (71045) provided on December 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles provided on December 18, 2019. 
 
You asked the Plan to pay for the sterile needles. You say that the Plan should pay this claim. The Plan denied your request. The Plan says payment for these items is included in the outpatient prospective payment system. 
 
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 find that CPT code A4215 payment is packaged into payment for other services. Therefore, there is no separate Ambulatory Payment Classification. Based on this information, we decided that Medicare rules for coverage of the sterile needles have not been met. Therefore, we decided that the Plan does not have to pay separately for the sterile needles provided on December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on May 1, 2019.
You asked the Plan to pay for the ambulance transports. You say that the transports were medically necessary.
The Plan denied your request. The Plan says non-emergency transport to and from a physician's office for an
appointment is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for services provided on May 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Keytruda injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the requirement for this drug is the cancer did not improve after receiving another
treatment for Hodgkin Lymphoma.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the request is for
first line therapy with pembrolizumab for classical Hodgkin lymphoma in a patient with a prior breast cancer
on arimidex and mantle cell lymphoma on Calquence. Pembrolizumab is not FDA approved for 1st line
treatment of Hodgkin lymphoma, is not supported by major drug compendia for 1st line use, and a search of the
medical literature did not find medical literature to support first line use. Hodgkin lymphoma has a high cure
rate with standard first line therapy. The service is not reasonable or medically 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Keytruda injection for the enrollee.