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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly
moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive,
longer duration of therapy will allow for measurable gains to be attained within a reasonable and 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 vision services provided on December 9, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for vision services. You say that the member has been seen by this office before. The
Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are innetwork
providers available for these services,
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for vision services provided on December 9, 2019 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the sales tax for the purchase on January 16, 2020.
You asked the Plan to reimburse you the sales tax. You say that the Plan representative told you that you would
be reimbursed 80% of the cost of the wig. The Plan denied your request. The Plan says they will reimburse you
80% of the cost of the wig but sales tax is not separately payable.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. However, the Plan representative told you the wig would be reimbursed at 80% so the Plan agreed.
Sales tax is not separately payable by Medicare. Therefore, we decided that the Plan does not have to reimburse
you the sales tax for the purchase on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the chair purchased on
August 30, 2018.
You asked the Plan to reimburse you for the seat lift mechanism of a seat lift chair. You say that you were told
the Plan would reimburse you for the chair. The Plan denied your request. The Plan says the claim was
untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the seat lift mechanism of a seat lift chair was not filed until December 12,
2019. This means that more than one calendar year from the date of service had passed before a claim was
filed. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of the
chair purchased on August 30, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 17, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were sent there by your doctor.
You say that you shouldn't have to pay the bill. The Plan denied your request. The Plan says the copayment
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 $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency Care"
benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit services provided on
December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit services. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
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 hospital outpatient clinic visit services
provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pemetrexed (Alimta) and pembrolizumab (Keytruda).
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drugs
are not indicated for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 requested drugs. Our physician
reviewer found that the request is for Pemetrexed and Pembrolizumab to be given with Carboplatin to treat
recurrent, symptomatic malignant pleural effusion in the setting of stage IV adenocarcinoma of the lung. The
requested combination is supported for use as first line therapy when EGFR, and ALK and other molecular
markers are negative. The required tests are pending for the enrollee so results are unknown. The requested
combination is not FDA approved for the requested use and it is not supported by any of the CMS approved
compendia. This reviewer did not find any supporting citations in a PubMed search. The use is not listed as not
indicated, not supported or not recommended in any of the compendia.
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 requested drugs have not been met. Therefore, we decided that the Plan does
not have to pre-approve pemetrexed (Alimta) and pembrolizumab (Keytruda).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 18,
2019.
You asked the Plan to pay for the periodontal maintenance. You say that you were approved for 3 cleanings per
year due to not being able to reach and floss your molar. The Plan denied your request. The Plan says the
charge or number of occurrences this procedure was performed has exceeded the contract limits.
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 requested items or services are not
among those covered under this benefit. The Plan contract includes 2 cleanings per year, however, periodontal
maintenance is a periodontic service and is not listed as being covered by the Plan. Therefore, we decided that
the Plan does not have to pay for the periodontal maintenance provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February
4, 2020.
You asked the Plan to pay for the dental service. You say that your ID card from the Plan says that you have
dental coverage. The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal
maintenance (D4910) provided on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on November 15, 2019.
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 these are excluded services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services received on
November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that on the date of service an
ambulance was dispatched to your home because of the multiple symptoms you were experiencing. You say
that you were incoherent, confused, and unable to move along with other issues. Because of this, 911 was
called and an ambulance and paramedics were dispatched. The responders evaluated you and you were
transported to the hospital. You stated that the denial is upsetting and you do not have the financial means to
support the additional bills. You say that the ambulance services were necessary and the bill should be settled
by the Plan. 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 pays for advanced life support (ALS), in
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMTParamedic
only in certain circumstances. Medicare allows ALS paramedic intercept services only when the
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow
the volunteer ambulance company to bill for the transport or BLS services.
The Plan has confirmed that the company that provided the paramedic intercept services does not have a
contract with the volunteer ambulance company that provided the transport services. Therefore, we decided
that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that discharge from acute IP to an inpatient rehabilitation facility is medically necessary to make significant gains necessary to be able to return home safely. The Plan denied your request. The Plan says 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee was medically stable with no evidence of need for supervision by PMR physician or needs acute rehabilitation nursing care. The enrollee may benefit from further physical therapy and occupational therapy but the enrollee does not require an intensive therapy program. The enrollee's rehabilitation needs can be met at a lower intensity setting such as in-home with services or in an outpatient setting. An 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 an IRF admission and services.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the deductible for the urgent care visit provided on January 7, 2020.
You asked the Plan to waive the deductible for the urgent care visit. You say that you weren't informed of the deductible. You say that your copayment for urgent care is $50. The Plan denied your request. The Plan says that the deductible 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 does not say in clear and accurate terms whether the deductible should apply to urgently needed services. We looked at your contract with the Plan. The Plan contract does not clearly say if the deductible should apply to urgently needed services because different benefits are listed. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for the urgent care visit provided on January 7, 2020.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2019
through November 10, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review indicates that the record showed 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from November 6, 2019 through November 10, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Fresnell prism press-on lens (V2718) provided January 17,
2020.
You asked the Plan to pay for the Fresnell prism press-on lens. You say that this provider was authorized by the
plan because this specialty is not in their network. This provider only bills for medical and was told by the plan
to seek reimbursement. The Plan denied your request. The Plan says enrollee's must receive their vision
services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when rendered by a preferred network provider.
We looked at the file and the Plan's rules. Routine vision care services are covered only when rendered by a
preferred network provider. Based on this information, we decided that the Plan's rules for coverage of the
Fresnell prism press-on lens have not been met. Therefore, we decided that the Plan does not have to pay for
Fresnell prism press-on lens (V2718) provided January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the hemoglobin laboratory services provided on December 19, 2019.
You asked the Plan to waive the copayments for the hemoglobin laboratory services. You say that you canceled this appointment a couple of days before the appointment. The Plan denied your request. The Plan says the claims were processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $35 copayment per day, per provider for Medicare-covered lab services. Review of the file shows that the services were obtained from this provider in an outpatient visit received on December 19, 2019. Your copayment requirement for the laboratory services is $35. However, the allowed amount for this service was $17.42. Since this is less than your copayment requirement, you were charged the lesser amount. You have been asked to pay a $17.42 copayment per day, per provider for the hemoglobin laboratory services. The hemoglobin laboratory services fall within the Medicare-covered lab services 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 copayments for the hemoglobin laboratory services provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular diagnostic testing rendered on November 26,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that molecular diagnostic testing for genitourinary
infectious disease is covered when medically necessary.
We looked at the file and Medicare rules. There is no documentation to support that the testing was medically
necessary for the enrollee. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular
diagnostic testing rendered on November 26, 2019.