Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 30,
2019 to December 31, 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 have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also
says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.
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 December 30, 2019 to December 31,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on February 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that the referring provider is 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 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 lab tests provided on February 25, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electrocardiogram reading (93010) provided December 9, 2019.
You asked the Plan to pay for the Electrocardiogram reading. You say that the claim was correctly submitted. The Plan denied your request. The Plan says payment for code 93010 is included in payment for the Emergency Room services.
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 93010 is not supported in the medical record. Specifically, no modifier was included to indicate this was a separate service. Payment for this service is included in the Emergency Room services (99291) submitted on the same claim. Based on this information, we decided that Medicare rules for coverage of the Electrocardiogram reading have not been met. Therefore, we decided that the Plan does not have to pay for an Electrocardiogram reading (93010) provided December 9, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an IV infusion. We decided that the Plan does not have to reduce the cost-sharing charges for an IV infusion to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for an IV infusion. You say that you should not owe anything for the IV infusion because you did not receive physician services. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for an IV infusion from $30.48 to $7.14.
The plan contract says that you must pay 20% coinsurance for Medicare Part B drugs. Therefore, you cannot be asked to pay more than 20% coinsurance for an IV infusion. We decided that the Plan has to reduce the cost-sharing charges for an IV infusion from $30.48 to $7.14.
We also decided that the Plan does not have to reduce the cost-sharing charges for an IV infusion to the amount you requested.
The plan contract says that you must pay 20% coinsurance for Medicare Part B drugs. The total allowed amount is $35.71 and 20% of that is $7.14. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for an IV infusion to the amount you requested.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 13, 2019
through April 25, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. 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 April 13, 2019 and discharged on April 25, 2019. You
were asked to pay a $360 copayment per day from April 13, 2019 through April 17, 2019, days 1-5 of your
inpatient stay. There were no copayment charges from April 18, 2019, day 6 of your inpatient hospital care
until your day of discharge April 25, 2019. Per your contract there is a $360 copayment per day required for
days 1-5. 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 April 13, 2019
through April 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on January 28, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for psychiatric services. You say that you confirmed with the receptionist prior to
services being rendered that the provider was in-network. The Plan denied your request. The Plan says there are
in-network providers available.
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 psychiatric services provided on January 28, 2020
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the requested item is
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is
met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Freestyle Libre 14 day sensor. Our
reviewer says that the item is not medically necessary. Our physician reviewer found you need to be taking
multiple shots per day of insulin to qualify for a CGM. You are taking one shot per day and do not seem to be
on an insulin that is usually adjusted daily according to blood glucose level. The criteria is not met and we are
not given any reason why use of the usual glucometer is not appropriate.
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 Freestyle Libre 14 day sensor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 27, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that The Plan denied your
request. The Plan says that there is a $300 copayment per one-way trip for emergency or non-emergency
ambulance services.
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 $300
copayment for one-way trip for emergency ambulance services and non-emergency ambulance services.
You have been asked to pay a $35 copayment for the ambulance transport. The ambulance transport falls
within the one-way trip for emergency ambulance services and non-emergency ambulance services benefit
category. This means that you have been asked to pay less than 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 ambulance transport
provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
You asked the Plan to pre-approve the mandibular partial denture. You say that your right temporal mandibular
joint is sore, and you believe you are chewing more on your left side. You also say that you believe the partial
denture will help you chew more equally and will relieve some of the pain you are experiencing. The Plan
denied your request. The Plan says the documentation shows that you have sufficient posterior teeth for
adequate masticatory function. The Plan also says that there is no evidence that providing a resin based
prosthesis will improve function or alleviate purported temporal mandibular dysfunction.
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. The Plan covers the
mandibular partial denture when the services are medically necessary and reasonable.
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 mandibular partial denture. Our
reviewer says that the criteria for coverage for a mandibular partial denture (D5212) have not been met. Our
physician reviewer found the documentation indicates that there is adequate bilateral occlusal contact for
adequate bilateral masticatory function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the mandibular partial denture have not been met. Therefore, we decided that
the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 2, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 2, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
medical records do not contain documentation of definitive laboratory results for 8-14 drug classes.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The documentation provided by the non-contract provider does not
contain documentation of the ordering physician's intent that the tests be performed. Based on this information,
we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we
decided that the Plan does not have to pay for the drug testing services provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift chair and heat and vibration for
lift chair.
You asked the Plan to pre-approve the lift chair and heat and vibration for lift chair. You say that please
reconsider the decision because without a lift chair it will be almost impossible for you to live your daily life.
The Plan denied your request. The Plan says this service is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the lift chair and heat and vibration for
lift chair. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the physician's records did not show a seat lift as the
treating practitioner's course of treatment. The notes do not support that the seat lift mechanism is part of the
physicians plan of treatment or that a seat lift will improve or retard/arrest the patient's condition. The records
did not mention his functional capabilities and there is are PT or OT evaluations to assess his ability to stand or
ambulate and there is no mention of these in the physician's office note dated 2/19/20 either. The items
requested do not meet the Medicare set definition of durable medical equipment, therefore, medical necessity is
not met. In addition, this NCD states that Heat and Massage Foam Cushion Pads are comfort items and not
primarily medical in nature. Medicare National Coverage Determination: NCD for Durable Medical Equipment
Reference List (280.1).
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 lift chair and heat and vibration for lift chair have not been met. Therefore,
we decided that the Plan does not have to pre-approve a lift chair and heat and vibration for
lift chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 21, 2020 to January 31, 2020.
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's condition no longer required daily skilled services at an inpatient SNF level of care.
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 January 21, 2020 to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee on October 23, 2019.
You asked the Plan to pay for these services. You say that there is a documented relationship between the ordering physician and enrollee. The Plan denied your request. The Plan says that the billed services were not supported.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from August
27, 2019 to August 29, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that that a severe medical condition requiring
hospitalization was not established in this patient.
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. 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 and/or observation care) would span two
midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for the acute
inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided to the enrollee from August 27, 2019 to August 29,
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: 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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not 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 the medical records do not show that you require daily skilled nursing and daily skilled therapy and an IRF level of care. The complexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The current medical status does not require intensive physician or nursing oversight in an IRF. Your functional level does o not require or indicate that this therapy must be in an IRF or can be tolerated in an IRF with an intensive level program. Medicare coverage criteria are not met. 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.