Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted
on 1/5/2020 with altered mentation and a syncopal episode. Workup revealed a non-ST elevation myocardial
infarction and right temporal and parietal lobe changes, consistent with an ischemic infarct. The enrollee was
medically managed, and remains with weakness and aphasia. She warrants one on one supervision with feeding
and is mostly minimal assist for mobility and functional transfers. Vital signs are stabilizing and there is no
sign of fever or toxicity.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, skin care, and
daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal assist for
functional transfers and activities of daily living, and warrants supervision for safe feedings. A less intensive,
longer duration of therapy can allow for measurable gains to be attained within a predicted period.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on May 19, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that the service was for ear wax removal. You say that the claim was not paid and you billed for $139. You also say that you had this service done a couple times over the last few years and claims have been paid. The Plan denied your request. The Plan says this is an out-of-network provider for your insurance. The Plan says that medical records were needed to determine if this was a medical necessity. The Plan also says that medical records were requested but not received. The Plans says that your service was coded as place of service-11 which is defined as a provider office. If your service had been coded as place of service-20 that would be defined as urgent care. Finally, the Plan states that to receive care from an out-of-network provider there needs to be three exceptions: emergent or urgently needed services, medical care that is not available with network providers, or kidney dialysis services when the member is temporarily outside the plan service area.
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 (99214) provided on May 19, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx test provided on July 31, 2019.
You asked the Plan to pay for the FoundationOne CDx test. 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 the FoundationOne CDx test provided on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the stockings should be covered.
The Plan denied your request. The Plan says the stockings are a wound care item which is non-covered under
the surgical dressing benefit because it does not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove 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 preapprove a pneumatic compression device
(E0652).
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 August 26, 2019.
You asked the Plan to pay for the services. You say that you have never received a bill from this provider. The Plan denied your request. The Plan says the out-of-network 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 August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rural health clinic or health center visit (G0511) provided on August 27, 2019 by the out of network provider.
You asked the Plan to pay for a rural health clinic or health center visit. You say that you have had this service covered in the past. The Plan denied your request. The Plan says this service was 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 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 a rural health clinic or health center visit (G0511) provided on August 27, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2019 through July 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2019 through July 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77065 and G0279) provided on September 21, 2019.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you shouldn't owe a copayment on this service because the radiologist felt it was needed. The Plan denied your request. The Plan says this service processed 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 basic imaging service. You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the basic imaging service 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 a diagnostic mammogram (77065 and G0279) provided on September 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925) and a vascular study (93978).
You asked the Plan to pre-approve a duplex scan of lower extremity arteries and a vascular study. You say that the requested services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that peripheral artery studies are only covered when specific criteria is met. 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 a duplex scan of lower extremity arteries and a vascular study. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for coverage. The requested items/services at issue in this case are not medically reasonable and 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 a duplex scan of lower extremity arteries and a vascular study have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925) and a vascular study (93978).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on January 28, 2019.
You asked the Plan to pay for the ground mileage and ambulance service. You say that the letter clearly states the enrollee was not enrolled in hospice until after the ambulance transport. 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 enrollee'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 the ground mileage and ambulance service provided on January 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair with elevating leg rests provided on June 24, 2019 and July 24, 2019 by the out of network provider.
You asked the Plan to pay for the standard wheelchair with elevating leg rests. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the standard wheelchair with elevating leg rests provided on June 24, 2019 and July 24, 2019 by the out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray, pharmacy, injection, and emergency room visit for evaluation and management provided on September 1, 2019.
You asked the Plan to pay for the physician services. You say that the claim has not been paid in full or under the terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan says the Medicare hospice benefit, under fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan says that 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 the hip x-ray, pharmacy, injection, and emergency room visit for evaluation and management provided on September 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Valsartan-Hydrochlorothiazide.
You asked the Plan to pre-approve Valsartan-Hydrochlorothiazide. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Valsartan-Hydrochlorothiazide is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Valsartan-Hydrochlorothiazide.
Benefits for Valsartan-Hydrochlorothiazide may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were having chest pain and having difficulty breathing. The ambulance personnel treated you and advised you to go to the hospital. You say that since the hospital they wanted to go to was far from your home, you decided that your spouse would drive you to a closer hospital. You say that the ambulance call was valid and you were never informed that the services would not be covered if you didn't take ride in the ambulance to the hospital. 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 July 1, 2019. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 19, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you have never been charged this
must in the past 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 $250
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received arthrocentesis on June 19, 2019. Therefore, you are responsible to pay the allowed amount of
$234.22, which is less than the $250 copayment.
You have been asked to pay $234.22 for arthrocentesis. Arthrocentesis falls within the outpatient surgery and
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on June 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service provided on June 17, 2019.
You asked the Plan to pay for the laboratory service. You say that the claim was not paid in full or under the
terms of the contract for the services provided to the member. The Plan denied your request. The Plan says
Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the
member's terminal illness.
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 member was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record
shows proof of hospice election from April 13, 2019 to December 8, 2019. Therefore, we decided that the Plan
does not have to pay for the laboratory service provided on June 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services on May 24, 2019.
You asked the Plan to pay for the diagnostic services. You say that the claim has not been paid in full. The Plan
denied your request. The Plan says Original Medicare is responsible for payment of all Medicare-covered
services related or unrelated to the member's terminal illness.
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 radiology services on May 24, 2019.