Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from April 29, 2019 through April 30, 2019.You asked the Plan to pay foracute 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 midnightsor 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 forthe acute inpatient hospital care provided from April 29, 2019 through April 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 9, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary. We find that the services are not supported in the medical record. Specifically, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided to on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the filling (D2393) provided from May 6, 2019 to September 26, 2019.
You asked the Plan to reimburse you for the dental services. You say that the book says "any licensed dental provider may provide services." You say that you should be reimbursed for the services. The Plan denied your request. The Plan says federal regulations do not allow this service to be covered by Medicare Advantage Health plans. The Plan also says that the provider was excluded from participating in federal programs at the time services were performed.
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, the dental services were performed by a provider on the OIG list of sanctioned providers. The dental services at issue were not emergency services. This means that the Plan cannot pay for the dental services that you received from May 6, 2019 to September 26, 2019. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the filling (D2393) provided from May 6, 2019 to September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing provided on March 6, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include a valid physician order for a presumptive screen test.
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 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing provided on March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approverehabilitation services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe rehabilitation services. You say that you have had great results in working with this provider and do not want to have to switch. Specifically since they offer in-home services.The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.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-approverehabilitation services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 29, 2019 to September 30, 2019. You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says report of the FIPS code is required to identify the county where the services were rendered. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 29, 2019 to September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided November 5, 2018 to November 6, 2018. You asked the Plan to pay forthe inpatient services. You say that inpatient services were medically necessary.The Plan denied your request. The Plan says the inpatientadmission was not preauthorized or medically necessary.The Plan must follow Medicare rules. Medicare rules say that providers must furnish medical records to support services billed.We looked at the file and Medicare rules. The records provided wereinsufficient to determine if the inpatient services were medically necessary. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forinpatient services provided November 5, 2018 to November 6, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on August 23, 2019.You asked the Plan to pay forthe ambulance services. You say that the ambulance services were medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.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 service was not medically necessary. Our physician reviewerfound documentation does not outline restrictions to the transfer by means other than ambulance.  Additionally, there is not documentation of isolation requirements or other lifesaving equipment.  Without the support of the documentation, medical necessity cannot be determined.  The denial is upheld.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 forservices provided on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the services provided. You say that forcing pathologists to report place of service 21 or 22 will have unintended consequences for hospitals. The Plan denied your request. The Plan says any service performed during an inpatient confinement is considered to be performed in an inpatient setting, and not in an outpatient setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. This means that payment to you for this service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the pathology services provided to the enrollee on October 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar Vertiflex interspinous spacer procedure provided to the enrollee on October29, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says there is no clear documentation to why the enrollee would not be indicated for standard decompression surgery.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 pay for the services provided. Our physician reviewer found that the provided device is considered experimental. More research is needed to determine the efficacy of the device. Therefore, the provided service wasnot medically reasonable and necessary to treat 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay forthe lumbar Vertiflex interspinous spacer procedure provided to the enrollee on October 29, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90792) provided June 26, 2019
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90792) provided June 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that this service was medically necessary. 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 domiciliary or rest home visit (99336) provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2019 to September 8, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2019 to September 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided from September 30, 2019 to October 4, 2019. You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee could have been transferred to an in-network facility for the inpatient services. 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 the post-stabilization inpatient care. Our reviewer says that the enrollee was stable for transfer to a plan facility. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation or admission level of care services. There was no documentation provided necessitating post stabilization care services. 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 post-stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided from September 30, 2019 to October 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 10, 2019 to July 9, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 10, 2019 to July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 90 of the plan's 2020 Evidence of Coverage.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 5, 2019.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers available. The services were not emergent or preauthorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee on December 31, 2018.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received SNF care provided on December 31, 2018. The enrollee is asked to pay a $160 copayment for the SNF care. The member started her benefit period on November 21,2018 and was there until November 30, 2018. This was the start of the member's benefit period; days 1 through 10 of the member's SNF benefits period at $0 copayment for member responsibility. Then the member continued her benefit period from December 01 through December 12, 2018 with provider This was for days 11 through 21 of member's SNF benefit period at $160 for day 21 for copayment for member responsibility. The member was assessed a $160 copayment for day 21, on December 12, 2018 with provider and therefore December 31, 2018 with provider, was day 22 of the benefit period for SNF services, which also assessed a $160 copayment. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee on December 31, 2018.