Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 18, 2020 and February 25, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you've had these shots in the past and weren't charged for them. 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 $250 for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay a total $425 for the arthrocentesis provided on February 18, 2020 and February 25, 2020.
Date of Service
Service
Standard Copayment
Member Liability
February 18, 2020
Arthrocentesis
$250
$250
February 25, 2020
Arthrocentesis
$250
$175
TOTAL:
$425
The arthrocentesis falls within the "Outpatient surgery including 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 the arthrocentesis provided on February 18, 2020 and February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient admission for approved total hip surgery.
You asked the Plan to pre-approve inpatient admission for approved total hip surgery. You say that the
requested inpatient admission is medically necessary. The Plan denied your request. The Plan says that the
requested inpatient admission is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 inpatient admission for approved total
hip surgery. Our reviewer says that the requested inpatient admission is medically necessary. Our physician
reviewer found this enrollee presents with a diagnosis of grade 3 osteonecrosis with collapse of the left hip. He
has been approved for left total hip replacement. Under consideration is a request for inpatient admission. This
enrollee's significant past medical history including stroke, hypertension, seizures, deep vein thrombosis, and
pulmonary emboli on chronic anticoagulation therapy, would support the medical necessity of inpatient
admission following major orthopedic surgery to allow for extended cardiovascular and hemodynamic
monitoring in a safe environment with seizure precautions. Therefore, the requested inpatient admission is
medically reasonable and necessary versus outpatient observation for the enrollee's approved total hip surgery.
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 admission for approved total hip surgery have been met. Therefore, we
decided that the Plan has to pre-approve inpatient admission for approved total hip surgery.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with recent diagnosis of dysuria and positive urinalysis (for UTI). The enrollee has chronic musculoskeletal pains. Function has declined; she is able to walk 40' with assist of a walker and perform gait and basic transfers with contact guard assist-to-standby assist. She has had a recent fall. Co-morbid conditions include atrial flutter and hyponatremia. She is afebrile and hemodynamically stable. The enrollee is now mostly contact guard assist-to-standby assist for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable and SNF is not medically necessary as it is custodial in nature (not skilled).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network urgent care office visit provided on
February 15, 2020.
You asked the Plan to pay for this service. You say that you thought this would be cheaper than the emergency
room. The Plan denied your request. The Plan says based on the medical records provided, you reported to an
urgent care physician that you had bug bites that had been present for one day and wanted them looked at. The
Plan says that this care was neither urgent or emergent and was not approved 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 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 service 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 an out of network urgent care office visit provided on February 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2018 to September 5, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was admitted to hospice services on August 10, 2018 and remained on hospice until her expiration. The Plan also says the SNF services are denied because the enrollee was enrolled in hospice.
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 skilled nursing services provided from August 10, 2018 to September 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on October 15, 2019. You asked the Plan to pay for the home visit. 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 a home visit provided on October 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says this would exceed your needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you have identifiable skilled nursing or therapy needs. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 power wheelchair.You asked the Plan to pre-approvea Group 2 power wheelchair. You say that you need a Group 2 power wheelchairThePlan denied your request. The Plan says the notes state you are able to ambulate with a cane.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. 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 Group 2 power wheelchair. Our reviewer says that a Group 2 power wheelchair is not medically necessary. Our physician reviewer found in this case, the enrolleeis not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker).  Therefore, this request is not 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 a Group 2 power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a
participating provider on July 5, 2019 to July 27, 2019.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you were told that your
health plan agreed not to charge you for the two additional days. The Plan denied your request. The Plan says
the correct copayment has been applied.
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 $0
copayment per day for days 1-20. There is a $100 copayment per day for days 21-100 for skilled nursing
facility.
You have been asked to pay a $0 copayment per day for days 1-20. There is a $100 copayment per day for days
21-22 for a skilled nursing stay. The total amount you are being asked to pay is $200 ($100 x days 21 & 22 =
$200). A skilled nursing stay falls within the skilled nursing facility 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 skilled nursing stay provided by a
participating provider on July 5, 2019 to July 27, 2019.
We note your complaint about being told that the health plan was not going to charge you for the additional
days. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.
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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no indication that you have a complexity of conditions which would benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You do require skilled physical therapy and occupational therapy, but you do not require treatment in an intensive rehabilitation therapy program. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 IRF care is not considered medically
reasonable and 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 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 based on review of the available records, the enrollee does not meet criteria for IRF
admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine
and rehab physician or needs acute rehab nursing care. Functionally given she is dependent now and was prior
to admission for a number of years, it is unlikely that she will improve her function with a short acute inpatient
rehab. The enrollee may benefit from further physical therapy and occupational therapy but does not require an
intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional
status and 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an early reset of your vision benefit. 
 
You asked the Plan to pre-approve an early reset of your vision benefit. You say that you did not realize you would need to wait a year and would like to fill your prescription. The Plan denied your request. The Plan says your routine vision benefit will be available a year after your previous date of service. 
 
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's routine vision benefit is administered on a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. The record shows that you previously received eyewear in December 2019. Therefore, you are next eligible for your vision benefit in December 2020. Based on this information, we decided that the Plan's rules for coverage of an early reset of your vision benefit have not been met. Therefore, we decided that the Plan does not have to pre-approve an early reset of your vision benefit.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on December 17, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You sent your bill in for review. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 forthe emergency room visit provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from September 5, 2019 to September 18, 2019.You asked the Plan to waive the coinsurance for the Part B injections. You say that the price has increased 75% and you are on a fixed income. You say the price increase will prevent you from getting the shots that you need. 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 20% coinsurance for chemotherapy and other drugs covered by Medicare Part B. You have been asked to pay $202.67 which is 20% of the allowed amount for the Part B injection on each date of service. The allowed amount is $1,013.36. ($1,013.36 x 20% = $202.67). ($202.67 + $202.67 = $405.34). The Part B injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the Part B injections provided from September 5, 2019 to September 18, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found initial PET scans for prostate cancer are not covered. A biopsy is required before PET scans can be authorized. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. You say that the requested sleep study is medically necessary.
The Plan denied your request. The Plan says the requested sleep study 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 a sleep study. Our reviewer says that
the requested sleep study is not medically necessary Our physician reviewer found coverage criteria for a
repeat PSG are not met. This enrollee has mild obstructive sleep apnea (OSA), but has been intolerant of CPAP
despite a previous CPAP titration study and two separate trials of home CPAP. The reasons for intolerance are
not provided. There has been no major change in health status or weight since the original PSG in 2018. This
enrollee appears to be intolerant of CPAP. There is already a diagnosis of OSA, and a successful PAP titration.
A repeat PSG will not improve the enrollee's tolerance of CPAP, and it is therefore considered not medically
necessary. A mandibular advancement device could be considered.
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 sleep study have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sleep study.