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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from December 2, 2019 through December 5, 2019.
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
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 post-stabilization care. Our physician reviewer found the provided records did not suggest that the patient was not stable for transfer. The patient appeared to be stable for discharge and transfer via ambulance to an in-network hospital at approximately 7:12 pm on December 2, 2019. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from December 2, 2019 through December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish, periodontal 
maintenance, and two gingival irrigations provided on January 9, 2020 by an OON provider. 
 
You asked the Plan to pay for the topical application of fluoride varnish, periodontal maintenance, and gingival 
irrigations. You say that you were misinformed on this provider's participation status. The Plan denied your 
request. The Plan says the treating provider is OON. The Plan also says that no benefits are available for 
procedures performed by OON providers or outside of the providers contracted period. 
 
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 
covered when they are received OON. The record shows that the Plan sent you a correspondence on November 
07, 2018 that advised you that the Plan was approving payment as a one-time exception due to Plan 
miscommunication, and that any additional payment for this provider would not be approved. Therefore, we 
decided that the Plan does not have to pay for the topical application of fluoride varnish, periodontal 
maintenance, and two gingival irrigations provided on January 9, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on March 19, 2019.
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 for specialist visits. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on March 19, 2020. You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 copayment for the specialist visit provided on March 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial upper and lower denture. 
 
You asked the Plan to pre-approve the partial upper and lower denture. You say that you are having a hard time 
eating and swallowing your food. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
partial upper and lower denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided by a participating 
provider on October 1, 2019 to January 30, 2020. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you do not agree with this coinsurance 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for services to treat kidney disease/all other members.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for dialysis. The total amount you are 
being asked to pay is $3,932.63. Dialysis falls within the services to treat kidney disease/all other members 
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 dialysis provided by a 
participating provider on October 1, 2019 to January 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 21, 2018 through 
April 22, 2018. 
 
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 patient had sufficient mix of chronic problems (metastatic cancer) and acute problems 
(renal failure, hyponatremia, hypotension, syncope - repeated) that it was reasonable at the time of admission to 
assume that greater than two midnights would be required. 
 
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 April 21, 2018 through April 22, 2018.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable bed frame/base and a foam rubber 
mattress for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items are not being obtained from a Medicare-certified supplier and are not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation submitted does not reveal a primarily medical reason to approve the adjustable bed 
frame/base or foam rubber mattress. The documentation does not support that the enrollee has a medical 
condition that these items would help ameliorate. The requested items are not medically necessary. There are 
no post-operative notes that indicates physical exam findings that would necessitate the requested items. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an adjustable bed frame/base and a foam rubber mattress for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 23, 
2020 through January 24, 2020. 
 
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 records do not show that at the time of admission the admitting physician 
reasonably expected that the patient would need more than two midnights of acute care in the hospital. 
Observation care would have been appropriate as the culture had already been resulted prior to admission, 
vitals were essentially stable, and the patient was improving on Augmentin already. 
 
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 January 23, 2020 through January 
24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist. 
 
You asked the Plan to pre-approve these services. You say that you have been seeing this provider for many 
years. The Plan denied your request. The Plan says the services are available from a provider within the 
primary 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 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-approve 
a referral to an out-of-network ophthalmologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you would like to go out-of-network 
because you would like to get this surgery done soon. The Plan denied your request. The Plan says these 
services can be provided in-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 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-approve 
an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 2, 
2019 through December 10, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not feel it is 
appropriate that you have two (2) copayments. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2019 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 shows that you were admitted on December 2, 2019 and discharged on December 10, 2019. 
You were asked to pay a $295 copayment per day from December 2, 2019 through December 7, 2019, days 1-6 
of your inpatient stay. There were no copayment charges from December 8, 2019, day 7 of your inpatient 
hospital care until your day of discharge December 10, 2019. Per your contract there is a $295 copayment per 
day required for days 1-6. 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 inpatient hospital care from 
December 2, 2019 through December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports the 
request for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines 
for coverage of LTACH care. The Plan says that the care needed can be provided in the current inpatient 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was recently hospitalized for aspiration pneumonia and shingles and 
discharged on July 3, 2020. Provider notes symptoms due to COPD exacerbation and oxygen supplement 
remained at baseline 8L with plan to continue oral steroids and non-invasive ventilation during sleep and as 
needed. Prognosis was noted as poor. The enrollee was also noted to have metabolic encephalopathy. There is 
no documentation provided necessitating admission to a LTACH. The enrollee's complex medical needs are 
being met in the current acute setting at this time. The enrollee is receiving appropriate care at the current acute 
care facility. The enrollee does not require services at the LTACH which are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids from a non-Plan provider. 
 
You asked the Plan to pre-approve these services. You say that you are not satisfied with the Plan's policy and 
coverage. The Plan denied your request. The Plan says the services are not covered from a non-Plan provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only through your plan. 
 
We looked at the file and the Plan's rules. The file shows that you are requesting hearing aids from a provider 
that is not your plan. Based on this information, we decided that the Plan's rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing 
aids from a non-Plan provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered from January 9, 2020 
to January 10, 2020. 
 
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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that physical therapy claims must be billed with the GP 
modifier. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required GP 
modifier. 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 physical therapy services rendered 
from January 9, 2020 to January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 24, 2020 through April 2, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe what happened during the surgery should be covered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 shows that you were admitted on March 24, 2020 and discharged on April 2, 2020. You were asked to pay a $350 copayment per day from March 24, 2020 through March 28, 2020, days 1-5 of your inpatient stay. There were no copayment charges from March 29, 2020, day 6 of your inpatient hospital care until your day of discharge April 2, 2020. Per your contract there is a $350 copayment per day required for days 1-5 for inpatient hospital care. 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 inpatient hospital care from March 24, 2020 through April 2, 2020.