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

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.The Plan must follow Medicare rules. The rules saythat 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for continuation of SNF 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with weakness and a fall. From a nursing perspective, the enrolleereceived oral medications.  The enrollee had stable vital signs. She had routine foley catheter care.  Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a moderate assist to dependent level with bed mobility and transfers. The enrollee required varying assist with activities of daily living.There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics (L3020).You asked the Plan to pre-approvefoot orthotics. You say that because you havetried your best to take preventive measures, that this orthotic should be covered.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided on July 3, 2020, through July 29, 2020.You asked the Plan to pay forthe home health services. You say that you would like reconsideration because this is not a duplicate claim.The Plan denied your request. The Plan says this is a duplicate claim and the original was previously processed and paid.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicarerules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates that payment was made for this episode of care on a prior claim and no explanation was providedas to why another claim was submitted.Therefore, we decided that the Plan does not have to pay forthe home health services provided on July 3, 2020, through July 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on August 9, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21.We looked atthe file and Medicare rules. The file shows that procedure code 71045 was billed with POS code 22; however, the enrollee was under inpatient status for the date of service at issue. The claim must be billed with POS code 21.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider.

You asked the Plan to waive the coinsurance for an injection. You say that you were told that it would be $14. 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 andcoinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The allowed amount is $1,062.60. The total amount you are being asked to pay is $212.52 ($1,062.60 x 20% = $212.52). The correct coinsurance has been applied to the injection that was provided. An injection falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of pre-malignant lesions (17003) provided on
February 13, 2020.
You asked the Plan to pay for the destruction of pre-malignant lesions. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says this is an add-on
code and the primary code has been denied.
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, we have confirmed that code the
destruction of pre-malignant lesions has a bundled relationship with code 17000 and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the destruction of pre-malignant
lesions (17003) provided on February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on June 4, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment 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 $60 copayment for outpatient diagnostic tests/complex diagnostic radiological services. You have been asked to pay a $60 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/complex diagnostic radiological 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 an MRI provided by a participating provider on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRestasis eye drops.You asked the Plan to pre-approveRestasis eye drops. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.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-approveRestasis eye drops.Benefits for Restasis eye dropsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 had network providers available who could have provided 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 forthe medical services provided on June 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 15, 2020. You asked the Plan to waive the copayment for the ultrasound. You say that you were not aware there was a $20 copayment. You say no one advised you that you would have this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 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 copayment for x-rays and ultrasounds. You have been asked to pay a $20 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services" 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 ultrasound provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from July 20, 2020, to July 28, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 did not pre-approve the laboratory services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided from July 20, 2020, to July 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on September 5, 2020.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.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, we have confirmed that code 71045 for the x-ray services has a bundled relationship with code 71100 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on September 5, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased August 12, 2020 from an out-of-network (OON) provider. You asked the Plan to pay for the hearing aids. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says hearing aids are not covered under any condition. 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. Although the Plan originally determined that your Plan never covered hearing aids, this is incorrect. They decided your appeal using an incorrect contract. Based on the EOC for the correct contract number, the Plan pays for hearing aids only when they are purchased from an in-network provider. We looked at the file and the Plan's rules. The file indicates that you purchased these hearing aids from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased August 12, 2020 from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from February 5, 2020, to February 10, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the Plan should pay this claim.The Plan denied your request. The Plan says that acute inpatient hospital level of care was 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 enrollee with a history of hypertension and diabetes mellituspresented to the ER on 2/5/2020 for the evaluation of cough, weakness and fever. The enrolleewas found to have influenza A and was started on Tamiflu and IV fluids andadmitted. Discharge plans concerns for safe discharge on 2/10/2020. The review has determined that the record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 forthe acute inpatient hospital care provided from February 5, 2020, to February 10, 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-approvea total electric hospital bed.You asked the Plan to pre-approvethe totalelectric hospital bed. You say that the semi-electric hospital bed is insufficient; it is too high and needs to be lower.The Plan denied your request. The Plan says the height adjustment is considered a convenience feature and is not a covered benefit under Medicare.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOmeprazole.You asked the Plan to pre-approveOmeprazole. You say that the enrollee had been using over the counter antacids for symptomatic control with very poor relief. You also say that Omeprazole twice daily keeps reflux symptoms well controlled.The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit. The Plan also says that outpatient prescription drugs are not covered under the enrollee's plan.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-approveOmeprazole.Benefits for Omeprazolemay be available under Medicare Part D.Contactthe 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 lab work provided 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 paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 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 had network providers available who could have provided 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 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe exercise equipment received on June July 6, 2020.You asked the Plan to pay forthe exercise equipment. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items received are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Review of the file shows that the Plan changed their coverage to allow for the purchase of fitness equipment under your Wellness reimbursement amount of $150. However, this onlyapplies to purchases made between October 1, 2020 and December 31, 2020. You received the equipment prior to October 1, 2020. Therefore, we decided that the Plan does not have to pay forthe exercise equipment received on June July 6, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 31,
2021.
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically
necessary. The Plan denied your request. The Plan says that the requested continuation of SNF care does not
meet criteria.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before January 31, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services after January 31, 2021.