Persius/hicric huggingface dataset:
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 August 22, 2019 at 5:04pm through August 23, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our physician reviewer found the review has determined that all inpatient care provided after 5:03 pm on August 22, 2019 through transfer at 5:50 pm on August 23, 2019 was not needed on an emergent basis as noted by the attending neurologist. The enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services. The post-stabilization care services at the nonPlan facility August 22, 2019 at 5:04pm through August 23, 2019 were not medically necessary and reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from August 22, 2019 at 5:04pm through August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the eye exam rendered on February 5, 2020.
You asked the Plan to waive the copayment these services. You say that you didn't think you were going to be charged. 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.
Review of the file shows that you received an eye exam on February 5, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes 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 the eye exam rendered on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered to you from November 15, 2019 to November 30, 2019.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 $320 copayment each day for days 1-5 for in-network inpatient hospital care.
Review of the file shows that you received inpatient hospital services from November 15, 2019 to November 30, 2019. You have been asked to pay a $320 copayment each day for days 1-5 for these services, for a total of $1,600. These services fall within the in-network 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 the inpatient hospital services rendered to you from November 15, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the ordering physician is also out-of-network.
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 outpatient lab work provided on January 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased November 8, 2019.
You asked the Plan to pay for the vision services. You say that it less expensive to go to this provider and you request reconsideration of the denial for reimbursement. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from a network provider per page 29 of the Evidence of Coverage. We looked at the file and the Plan's rules. Vision services must be provided by a network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased November 8, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 25, 2019.
You asked the Plan to pay for ambulance services. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says fee-for-service Medicare covers attending all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 12, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on February 27, 2019 to March 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that reimbursement it necessary based on the Indian Health Care Improvement Act. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available in the enrollee's area that are available 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 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 and physician services provided on February 27, 2019 to March 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve follow up services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
follow up services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amino acid therapy.
You asked the Plan to pre-approve the amino acid therapy. You say that amino acid therapy is not available in New Mexico. The Plan denied your request. The Plan says amino acid therapy is not approved by the United States Food & Drug Administration (FDA) to treat specific diseases. The Plan also says that it is not considered the standard of care for treatment of Parkinson's Disease.
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 pre-approve the amino acid therapy. Our reviewer says that the requested amino acid therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found amino acid therapy has not been demonstrated to be of clinical benefit in the management of Parkinson's Disease in any well-designed clinical studies. The reviewer found, in this setting, not only would the proposed therapy not be consistent with the accepted standards of medical practice for the diagnosis or treatment of your condition, but the proposed course of treatment would otherwise be experimental or investigational in nature. Therefore, the reviewer found that the service would not meet Medicare criteria for coverage. 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 amino acid therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve amino acid therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 13, 2020.
You asked the Plan to pay for the services. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says the services were not authorized.
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 to you by an out-of-network provider on January 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided to the enrollee on September 19, 2019.
You asked the Plan to pay for ophthalmological services. You say that the claim should be paid. The Plan denied your request. The Plan says while enrolled under the Medicare hospice benefit, Original Medicare is responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided to the enrollee on September 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided to the enrollee on January 9,
2020.
You asked the Plan to pay for hospital services. You say that the enrollee was not enrolled in hospice on the
date of service. The Plan denied your request. The Plan says fee-for-service Medicare covers attending all care
unrelated to the terminal illness until the first day of the month following the month in which hospice was
revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on January 6, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for initial hospital care
provided to the enrollee on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene expression testing provided on July 30, 2019.
You asked the Plan to pay for the gene expression testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The documentation does not support that the gene expression testing at issue in this appeal, was not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the gene expression testing provided on July 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections, 2ml, once a week for 3 weeks.

You asked the Plan to pre-approve Euflexxa injections. You say that the enrollee would benefit from Euflexxa injections. The Plan denied your request. The Plan says Euflexxa is subject to step therapy. The Plan also says documentation supporting the medical necessity for a step therapy exception was not received.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Euflexxa injections. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug(s), Monovisc and Orthovisc. The reviewer also found the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections, 2ml, once a week for 3 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652).
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 20, 2020 with psychosis. Based on the submitted records, it is not expected that the enrollee will improve in a reasonable period of time, as she is not showing dangerousness to herself or others. She has no delusions or auditory or visual hallucinations. She is cooperative care without any aggressive behaviors. It does not appear that active treatment is taking place. The inpatient psychiatric services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room visit provided to the enrollee on September 21, 2019.
You asked the Plan to pay for emergency room services. You say that the claim should be paid. The Plan denied your request. The Plan says while enrolled under the Medicare hospice benefit, Original Medicare is responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for emergency room visit provided to the enrollee on September 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical extraction (D7210) provided on November 1, 2019 by an out of network dentist.
You asked the Plan to pay for the dental service. You say that you understand the provider in this case is not an approved provider. You say that due to a previous dental visit at another office, you needed your tooth removed urgently. You say that you had an exposed nerve and broken tooth. You say that you went to the dental office that opened first in the morning. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says dental services that you receive out of network are not covered.
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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical extraction (D7210) provided on November 1, 2019 by an out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.