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 February 1, 2019
to March 2, 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 Skilled
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 8, 2018
to March 31, 2019. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from February 1, 2019 to March 2,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 27, 2020 to
February 10, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says generally
you must receive your care from a network provider for our plan to cover the services.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for chiropractic services provided from January 27, 2020 to February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provide on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained by the facility or the provider.
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 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 skilled nursing services provide on January 15, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab (J9312). You asked the Plan to pre-approve Rituximab. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 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 Rituximab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of nephrotic syndrome and Stage 4 kidney disease. Review of compendia does not support the use of Rituximab for the enrollee's conditions. Without the support of the compendia, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab (J9312).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemical cauterization procedure
provided on July 9, 2019.
You asked the Plan to waive the copayment for the chemical cauterization procedure. You say that you are
asking the Plan to reconsider paying $168.65. You say the service should be considered as an outpatient
service. 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 $325
copayment for surgical services at an in-network outpatient hospital facility. For this date of service, you have
been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for
outpatient surgery.
You have been asked to pay a $168.65 copayment for the chemical cauterization procedure. The chemical
cauterization procedure falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The record shows the chemical cauterization
procedure is considered an outpatient surgical procedure.
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 chemical cauterization procedure provided on July 9,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approve a continuous glucose monitor. You say that your doctor recommended a continuous glucose monitor.The Plan denied your request. The Plan says your medical assistant advised that you do not use insulin 3 or more times a day and you only test once a day.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 16, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a domiciliary, rest home visit provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 19, 2019 from a nonparticipating
provider.
You asked the Plan to pay for the hearing aids. You say that the prices of the in-network hearing aids were too
high so you went to this provider to obtain the hearing aids. The Plan denied your request. The Plan says you
do not have out-of-network benefits.
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 hearing aids purchased on August 19, 2019 from a
non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on March 9, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says
that no prior authorization was obtained.
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 lab tests provided on March 9, 2020 by an out of
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes G0481 and 80307 provided on October 2, 2019.
You asked the Plan to pay for CPT codes G0481 and 80307. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. We find that CPT code G0481 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 8-14 drug classes was performed. Medicare rules also say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for CPT code 80307 is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Based on this information, we decided that Medicare rules for coverage of CPT codes G0481 and 80307 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes G0481 and 80307 provided on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 14, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe out of network medical services. You say that no referral was obtained by the provider's office upon referral for the procedure. You say that the procedure was medically necessary because of Radiation cystitis. You say that the medical records should be reviewed and the claim should be reprocessed for payment.The Plan denied your request. The Plan says the non-urgent services were not authorized. The Plan says that the enrollee is required to utilize network providers when possible and available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 January 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit and arthrocentesis provided on February 11, 2020, February 18, 2020, and February 25, 2020.You asked the Plan to waive the copayment forthe office visit and arthrocentesis. You say that you had injections and are being charged a copayment 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 for each specialist visit for Medicare-covered benefits. Covered services include consultation, diagnosis, and treatment by a specialist. You have been asked to pay a total of $120 for the office visit and arthrocentesis. Date of Service Service Standard CopaymentMember LiabilityFebruary 11, 2020Office Visit$40$40February 18, 2020Arthrocentesis$40$40February 25, 2020 Arthrocentesis $40$40TOTAL:$120  The office visit and arthrocentesis fall within the "Physician/Practitioner services, including doctor's office visits" 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 office visit and arthrocentesis provided on February 11, 2020, February 18, 2020,and February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on November 15, 2019. 
 
You asked the Plan to waive the copayment for the facility fee. You say that you have had this same procedure performed in a physician's office. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for Medicare-covered surgical, IV therapy, and blood transfusion services.  
 
You have been asked to pay a $250 copayment for the facility fee. The facility fee falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 facility fee provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020 and March 18, 2020.
You asked the Plan to pay for the physician's 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 physician's services provided on February 25, 2020 and March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 27, 2019 to November 30, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were misdiagnosed with pneumonia and disagree with the 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 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 $295 copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from November 27, 2019 to November 30, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-3 (November 27, 2019 to November 29, 2019). $295 (copayment) x 3 (inpatient days) = $885. 
 
You have been asked to pay the total copayment amount of $885 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 for an inpatient hospital stay from November 27, 2019 to November 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 2 standard 3 wheeled power operated vehicle.
You asked the Plan to provide a Group 2 standard 3 wheeled power operated vehicle. You say that the enrollee
needs a Group 2 standard 3 wheeled power operated vehicle. The Plan denied your request. The Plan says a
Group 2 standard 3 wheeled power operated vehicle is a safety risk for the enrollee.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that the enrollee cannot safely operate the PMD being requested. This means that Medicare
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a
Group 2 standard 3 wheeled power operated vehicle.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee's condition is not at a level of complexity that requires an intensive and coordinated interdisciplinary approach, including physician visits at least three times weekly.
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 enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. No acuity or complexity of medical or nursing care for an IRF stay. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's medical stability. 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.