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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that his treating physical therapists believe that SNF placement is required due to his loss of function. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not necessary. Our physician reviewer found the member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation from the hospital to your residence (A0428-HR) provided on February 23, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford the extra $150 copayment and did not request the ambulance trip home. The Plan denied your request. The Plan says this 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 $150 copayment per one-way ambulance trip. You have been asked to pay a $150 copayment for the one-way ambulance services. 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 ambulance transportation from the hospital to your residence (A0428-HR) provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colonoscopy provided on December 29, 2020.

You asked the Plan to waive the deductible for the colonoscopy. You say that the colonoscopy should not apply to the deductible. You say you are taking every precaution to avoid a reoccurrence of colon cancer. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that applies towards in-network colonoscopies.

The colonoscopy you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards in-network colonoscopies for an in-network ambulatory surgical center. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on December 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the colonoscopy provided on December 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on November 6, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and 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. 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 ambulance services provided on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 29, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the services billed.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 80307 and HCPCS G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 7, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 7, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 7,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care would be the best option. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not necessary. Our physician reviewer found the beneficiary is 92 years old with dementia and cervical odontoid fracture. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He had difficulty tolerating his neck brace and exhibited wandering behaviors. Regarding rehabilitation services, the beneficiary received physical therapy in the home setting. The beneficiary was at a supervision to stand by assist level with functional mobility including gait to 175 feet with a rolling walker. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, skilled therapy is not required on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forCOVID-19 testing provided on October 6, 2020.You asked the Plan to pay forthe COVID-19 testing.The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to theterminal 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. 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 forCOVID-19 testing provided on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation provided on December 18, 2020.
You asked the Plan to pay for the air ambulance transportation. You say that the ground transportation time would have been at least 35 minutes.
This would have been hazardous and delayed due to rush hour traffic which could have worsened the enrollee's health. The Plan denied your request. The Plan says the enrollee was medically stable since the fall/injury had occurred one day earlier. There is no documentation of altered mental status, focal neurologic deficits, nor evidence of a cerebrospinal fluid leak or basilar skull fracture.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transportation. Our reviewer says that the air ambulance services provided do not appear to be medically reasonable and necessary. Our physician reviewer found the patient is a 73-year-old male with a fall, hitting his head the day prior without loss of consciousness. He presented to the walk-in-clinic and was found to have a laceration, dried blood to the back of his head. Emergency medical services (EMS) were called. He was evaluated and found with stable vital signs, normal neurological exam, and Glasgow 15. A closed head injury was suspected. He was transported via air ambulance to the emergency room as the estimated travel time via ground transport would have been around 35 minutes. The documentation does not support that ground transportation would have posed a threat to the patient as there were no objective signs or symptoms suggestive of an acute closed head injury or other emergent condition. 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 air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 8, 2020.
You asked the Plan to pay for the services. 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 8, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the air ambulance transportation provided on July 13, 2020.
You asked the Plan to pay for the air ambulance transportation. You say that it is felt that this enrollee required air ambulance transportation to the better equipped facility in order to reduce risks to her health. The Plan denied your request. The Plan says that air ambulance transport services, by means of either fixed-wing or rotary-wing aircraft may be covered only if the client's medical condition requires immediate and rapid air ambulance transportation that could not have been provided by advanced life support ground transport. The Plan feels ground transport could have been utilized.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transportation. Our reviewer says that the documentation supports the medical necessity of the air ambulance services rendered. Our physician reviewer found the enrollee is a 76-year-old woman with a history of coronary artery disease with prior bypass surgery, hypertension, and end-stage renal disease. The enrollee presented to the hospital with shortness of breath and was diagnosed with a myocardial infarction and pulmonary edema. The enrollee was placed on BiPAP. The enrollee was transferred to another hospital for a higher level of care, with cardiology services that were not available at the first hospital. The records support that the transferring hospital did not have appropriate facilities to manage the enrollee's condition. The enrollee's condition was such that transportation by any means other than ambulance was contraindicated. In addition, her condition was such that the time needed to effectuate transportation via ground ambulance posed a threat to her survival and seriously endangered her health. 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 air ambulance transportation have been met. Therefore, we decided that the Plan has to pay for the air ambulance transportation provided on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the records provided support the medical necessity of the transportation services in dispute. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We 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 ambulance services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee had nausea and vomiting for 2 days related to personal stress. The EMS arrived and found her to be sitting upright on the couch with stable vital signs. The enrollee was transported via ambulance to the emergency room and was given Zofran.
The provided documentation does not support that the other means of transport were contraindicated for this enrollee. The documentation does not support that the enrollee needed expertise or special equipment during the transport. The documentation does not support that the ambulance transport on October 10, 2020, was medically reasonable and necessary for the enrollee. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the Vertiflex device. The Plan denied your request. The Plan says this is not medically necessary.
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 Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 medically necessary. Our physician reviewer found you were admitted to the hospital for slurred speech, weakness, and rigidity. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
You have skilled therapy needs but do not require an intensive program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 12, 2021.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided from the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on December 1, 2020.

You asked the Plan to pay for the dental service. You say that 50% of the bill should have been paid. The Plan denied your request. The Plan says fillings have a 50% coinsurance. The Plan also says that dental services are paid based on the Maximum Allowable Charge (MAC). The Plan also says that the claim was processed correctly.

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 and crown is listed as covered, dental services are paid based on the maximum allowable charge. The record shows that the maximum allowable charge for the crown is $520. $520 x 50% coinsurance = $260. Additionally, out of network providers may bill the enrollee for any amount greater than the maximum allowable charge. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on December 1, 2020.