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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 7, 2020 through February 9, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that this was one continuous stay. 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 February 7, 2020 and discharged on February 9, 2020. You were asked to pay a $250 copayment per day from February 7, 2020 through February 8, 2020, days 1-2 of your inpatient hospital care. You were discharged on February 9, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-5. Your EOC states, your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type, including Inpatient Rehabilitation facilities, Long Term Acute Care (LTAC) facilities, Inpatient Acute Care facilities, and Inpatient Psychiatric facilities. 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 February 7, 2020 through February 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the services wereneeded to help get you up after a fall and to check your physical condition. You say that the ambulance came to your home, but did not transport you. You asked the Plan to reconsider their denial.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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 21, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spinal canal
(72141) provided on March 25, 2020.
You asked the Plan to pay for an MRI of the spinal canal. You say that this code is payable. The Plan denied
your request. The Plan says this service is part of another reported service.
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 72141 is not supported in the medical record. Specifically, this code has status indicator
of Q3, which indicates that payment for this code is packaged into another code. Based on this information, we
decided that Medicare rules for coverage of an MRI of the spinal canal have not been met. Therefore, we
decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spinal canal (72141)
provided on March 25, 2020.
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 LTACH care is medically necessary for ongoing acute care.The Plan denied your request. The Plan says the services needed could be provided in another setting.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 admitted to the acute care hospital on July 2, 2020 with shortness of breath. The enrollee has acute-on-chronic respiratory failure and is now on continuous BiPAP. He is to receive IV antibiotics for osteomyelitis until July 30, 2020. The enrollee is on hemodialysis for renal failure, with potential signs of renal recovery. On July 14, 2020, the enrollee was comfortably on CPAP. The plan for physical therapy is 2-3 times per week, with a duration of 1 week. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee requires services at the LTACH which are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dilaudid tablets for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for chronic pain syndrome. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dilaudid tablets for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on January 7, 2020.
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 Healthcare Common Procedure Coding System (HCPCS) G0481 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of HCPCS code G0481 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed." 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. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found no provider records correlating to the DOS have been submitted for review. No test results have been submitted for review. Therefore, the documentation does not support that the testing was medically necessary, reasonable or performed. 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 have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on January 3, 2020.You asked the Plan to pay for the  fixed partial denture sectioning. You say that you would like reconsideration because this service was medically necessary.The Plan denied your request. The Plan says per the member's EOC, the member does not have comprehensive dental coverage.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. Specifically, per your Office Reference Manual, CPT code D9120 is not a covered benefit.Therefore, we decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Binimetinib and Encorafenib for the enrollee.You asked the Plan to pre-approve these drugs. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that there is no data to support the safety and/or efficacy of the requested regimen of pembrolizumab, binimetinib, and encorafenib for treatment of malignant melanoma.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 these drugs. Our reviewer says that Keytruda, Binimetinib and Encorafenib are not medically reasonable and necessary for the enrollee in this case. Keytruda is FDA approved and compendium supported for treatment of metastatic cutaneous melanoma.However, the requested combination is not listed in the FDA approval nor any of the compendia. The NCCN compendium specifically states:Preferred second-line or subsequent systemic therapy* option as a single agent for metastatic or unresectable disease** after disease progression or maximum clinical benefit from BRAF targeted therapy. Therefore, the NCCN specification states the requested combination is not indicated, not supported and not recommended. Our physician reviewer found that the enrollee's condition does not meet criteria for these drugs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these drugs have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda, Binimetinib and Encorafenib for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 31, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you were sent against your will for psychiatric services.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 $175 copayment per one-way trip by ground or air ambulance.You have been asked to pay a $175 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on December 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that you are not fit to be released and cannot care for yourself. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled care from a nurse or therapist. The Plan says that continued assistance with routine daily activities could be safely provided at the custodial 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications, had stable vital signs, and was treated with compression stockings. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee was independent with bed mobility and at contact guard assist with functional mobility, including gait to 400 feet with a rolling walker. The enrollee required varying assist with activities ofdaily living. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of a CPAP with humidifier.You asked the Plan to pre-approvecontinued use of a CPAP with humidifier. You say that the enrollee needs continued use of the CPAP.The Plan denied your request. The Plan says the documentation shows the enrollee is not adhering to therapy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows the enrollee is not compliant with CPAP usage. Based on this information, we decided that Medicare rules for coverage of continued use of a CPAP have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of a CPAP with humidifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oximeter.You asked the Plan to pre-approvean oximeter (E0445). You say that you need to monitor your oxygen saturation.The Plan denied your request. The Plan says oximeters are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Oximeters are statutorily non-covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvean oximeter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean alveoloplasty in conjunction with extractions (D7311) and alveoloplasty not in conjunction with extractions (D7321).You asked the Plan to pre-approvethe alveoloplasties. The Plan denied your request. The Plan says theseservices are not listed in the enrollee's dental handbook and are not covered.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 applyin 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-approvean alveoloplasty inconjunction with extractions (D7311) and alveoloplasty not in conjunction with extractions (D7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained 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 lab work provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay forthe self-administered drugs provided from February 29, 2020 to March 2, 2020.You asked the Plan to pay forthe self-administered drugs. You say that the attending doctor requested the drugs and you did not question what you are told to take.The Plan denied your request. The Plan says that self-administered drugs are not covered by Medicare during emergencyroom or observation services.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted the requested list of the unpaid self-administered drugs.We are therefore unable to determinewhether the unpaid drugs are covered by your Medicare Part B benefit or not. Therefore, we decided that the Plan has to pay forthe self-administered drugs provided from February 29, 2020 to March 2, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF services are medically necessary.The Plan denied your request. The Plan says coverage criteria is 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 enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status and fatigue requires or can fully tolerate an intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the 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, the enrollee is mostly minimal 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. An IRF intensity is not warranted. 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.