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

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on August 7, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the provider did not apply for prior authorization. You say that the bill isdue to necessary emergency care.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 $200 for each one-way Medicare-covered ambulance transport.You have been asked to paya$200 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 isa 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 August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient rehab services providedfrom October 3, 2018 through October 24, 2018.You asked the Plan to waive the copayment forinpatient rehab services. You say that you did 20 days of rehab and were told before you checked in that it was approved and you would have no copay.ThePlan 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 October 3, 2018 and discharged on October 24, 2018. You were asked to pay a $295 copayment per day from October 3, 2018 through October 8, 2018, days 1-6 of your inpatient stay. There were no copayment charges from October 9, 2018, day 7 of your inpatient hospital care until your day of discharge October 24, 2018. 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 forinpatient rehab services provided fromOctober 3, 2018 through October 24, 2018
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your medical complexity is low, and you are unlikely able to participate in an intensive therapy program.
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 physician reviewer found that you are status-post fall as described above and are receiving home-based care. Your medical conditions appear stable. There are no wound care needs. You are in an outpatient setting and do not require medical oversight of your condition at an acute hospital level of care. You require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, you do not require an intensive therapy program. There is no significant injury or identified new reversible impairing condition. You would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 10, 2019 by out of network provider
You asked the Plan to pay for an office visit. You say that the same services was provided last year and you were not aware a prior authorization was required. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the plan advised that the provider was out-of-network prior to her visit.
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 an office visit provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 21, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that the urgent care doctor sent you to see an orthopedic specialist and did nothing to treat you. 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 $65 copayment for Medicare-covered urgently needed care visits. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you received an x-ray and given a prescription.
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 urgent care visit provided on July 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 19, 2019 by the out of
network provider.
You asked the Plan to pay for laboratory test. You say that you are not able to pay additional bills but need to
have this testing. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 19, 2019
by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram services provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation received did not support this service as a separately identifiable service, warranting being separately reimbursed.
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 code 93010 is "Electrocardiogram, routine ECG with at least 12 leads." 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 supported by the records submitted. Our physician reviewer found the documentation submitted does not appear to include provider documentation for the date of service in question. It appears the documentation submitted is part of a utilization review. There appears to be excerpts from physician records, however, the physician's name and signature are not present. 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 electrocardiogram services provided to the enrollee on August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia (denosumab).
You asked the Plan to pre-approve Prolia. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because Prolia is a second line therapy and the enrollee has not tried and failed a first line medication called a bisphosphonate.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for Prolia. Our physician reviewer found the Plan requires a trial of or intolerance to a bisphosphonate before it will authorize Prolia. The provided records do not indicate any reason the enrollee could not tolerate a bisphosphonate such as zoledronic acid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia (denosumab).
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 has had a complicated hospital course with pneumonia, cholecystitis,
cardiogenic shock secondary to severe mitral regurgitation, and respiratory failure requiring mechanical
ventilation and tracheostomy placement. The enrollee was weaned from the ventilator but still requires
supplemental oxygen via tracheostomy. The enrollee is also on a continuous milrinone infusion for an
indefinite period. Attempts to titrate this medication have resulted in hypotension. The enrollee was
transitioned to oral diuretics. However, they also will require titration due to recent severe hyponatremia
secondary to diuretic use. The enrollee is not required to discharge elsewhere to get ongoing acute level care.
The enrollee requires continuous infusion of intravenous milrinone, supplemental oxygen, tracheostomy care,
and therapy services, all of which can be safely done in the current acute care setting.
There is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute
level of care hospital services and is receiving appropriate care at the present acute care facility. The review has
determined that the enrollee does not require services at the LTACH that 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.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee's condition is not medically complex and does not require an interdisciplinary approach to oversee rehab care.The Plan must follow Medicare rules. The rules say that IRFadmission 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 physician reviewer found that the enrollee is at moderate assist for ambulation and transfers, and minimal assist for activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services (99491) provided on September 30, 2019 by the out of network provider.
You asked the Plan to pay for chronic care management services. You say that the facility at Colonial Oaks requested the enrollee be seen by one of their nurse practitioners. You requested the Health Plan review the medical records and issue payment. The Plan denied your request. The Plan says they did not find a valid referral on file for the service in question. In addition, the services were not urgent or emergent. They do not deny the medical necessity of the services however, authorization was not obtained.
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 chronic care management services (99491) provided on September 30, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ajovy.
You asked the Plan to pre-approve Ajovy. You say that the samples of this medication has helped the enrollee decrease the number of headaches per month. The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.
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 Ajovy.
Benefits for Ajovy 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance service provided by the facility on August 27, 2019 and rehab services provided by the facility on August 30, 2019
You asked the Plan to waive the copayments for the ambulance services and rehab services. You say that you had reached your maximum out of pocket so there should be no copayments for the services. The Plan denied your request. The Plan says out-of-network claims were being applied incorrectly towards the out of pocket which then seemed to be met.
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 have a $3400 out-of-pocket maximum for in-network covered services. You had not met the maximum at the time the services were rendered. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayments for the ambulance service provided by the facility on August 27, 2019 and rehab services provided by the facility on August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a hypoglossal nerve stimulator (0466T and 64568).
You asked the Plan to pre-approve the implantation of a hypoglossal nerve stimulator. You say that you need this procedure to treat your sleep apnea. The Plan denied your request. The Plan says this procedure is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that Hypoglossal Stimulation for the treatment of Obstructive Sleep has been determined to be not reasonable and necessary. We looked at the file and Medicare rules. The service you have requested has been determined to be not reasonable and necessary and therefore is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the implantation of a hypoglossal nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a hypoglossal nerve stimulator (0466T and 64568).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex) procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough medical evidence that shows the procedure is safe and helpful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. More research is needed to show safety and efficacy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex) procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider
You asked the Plan to pre-approve the ankle foot orthosis and additions (L1970, L2210 and L2820). You say that you believe the brace should be covered because it helps you to keep your balance and prevent falls. The Plan denied your request. The Plan says there are network providers in your area that can provide this service.
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 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. 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 the medical services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe reflux test provided on June 18, 2019.You asked the Plan to waive the copayment forthe reflux test. You say that you were notinformed you would have a copayment.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 $300 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay a $300 copayment for the reflux test. The reflux test falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa 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 reflux test provided on June 18, 2019