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

We decided that the Plan does not have to pay for the inpatient hospital services rendered on May 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were unauthorized post-stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the enrollee was stable for transfer to a network facility. Our physician reviewer found the enrollee presented to the emergency room (ER) with chest pain after one dose of home sublingual nitro. She received one dose of sublingual nitro, one dose of intravenous morphine, sliding scale subcutaneous insulin, and one dose of Zofran in the ER. Her symptoms resolved and she was admitted to telemetry. The records indicate that she was hemodynamically stable and appropriate for transfer to a network facility after the ER evaluation. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression wraps.
You asked the Plan to pre-approve compression wraps. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that compression wraps are covered only when they
are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient
compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression wraps.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 5, 2020, to November 14, 2020.
You asked the Plan to pay for the SNF services provided from November 5, 2020, to November 14, 2020. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee elected Hospice on November 5, 2020. The Plan says that while on Hospice, SNF level benefits are not covered by the health plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 5, 2020, to November 14, 2020.
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 is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xembify.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has a history of common
variable immune deficiency. The requested Xembify is for a formulation of immunoglobulin that is
subcutaneous. The enrollee has a primary humoral immunodeficiency, which is the indicated use of the
requested drug. Therefore, the requested drug is medically necessary and reasonable to treat the enrollee's
condition.
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 services have been met. Therefore, we decided that the Plan has to preapprove
Xembify.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for arthroplasty provided on November 2,
2020.
You asked the Plan to waive the coinsurance for arthroplasty. You say that you feel that the charges should be
reprocessed as inpatient. The Plan denied your request. The Plan says the claims were processed correctly, and
you are being charged the correct 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 20%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received arthroplasty on November 2, 2020, at an outpatient hospital facility. The total allowed amount is
$13,198.75 and 20% of that is $2,639.75.
You have been asked to pay the total coinsurance amount of $2,639.75 for arthroplasty. Arthroplasty 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 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 arthroplasty provided on
November 2, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our physician reviewer found based on the documentation provided, you do qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning below her January baseline. Due to several recent hospitalizations, it is unclear whether you have received the full benefit from therapy or reached a new plateau in function. Daily skilled services are required to establish a maintenance program, prevent deterioration of your condition and to establish whether you have reached a new functional baseline. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 3, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you were not charged for the same services in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall 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 for ambulance services provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on October 7, 2020.
You asked the Plan to pay for the laboratory test. You say that you have to see a different doctor to undergo a drug screening. The Plan denied your request. The Plan says this provider is not a network with the Plan.
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 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 laboratory test provided by an out-of-network provider on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for grafts (15769 and 15771) provided on August 5, 2020.
You asked the Plan to pay for grafts. You say that these codes are supported. The Plan denied your request. The Plan says these codes are not sufficiently documented.
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 15769 is grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) and 15771 is grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate. 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 grafts. Our reviewer says that these codes are not supported. Our physician reviewer found there is no documentation of these procedures in the operative report. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of grafts have not been met. Therefore, we decided that the Plan does not have to pay for grafts (15769 and 15771) provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect testing provided on September 29, 2020.
You asked the Plan to pay for CxBladder Detect testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CxBladder Detect testing is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder Detect testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder Detect testing provided on September 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care provided on November 3, 2020.You asked the Plan to pay forthe subsequent nursing facility care. The Plan denied your request. The Plan says this service required 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 did not pre-approve the servicesat issue. 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 forsubsequent nursing facility care provided on November 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 4, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the physician service. You say that the services were denied for no authorization. You also say that the services were necessary. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that authorization was not obtained prior to when the services were rendered to the enrollee.
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. Although the Plan offers a Point of Service (POS) option for certain services, prior authorization is required. 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 subsequent nursing facility care provided on August 4, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 skilled nursing services provided on June 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lower extremity orthoses provided on February 17, 2020.
You asked the Plan to pay for lower extremity orthoses. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the documentation submitted does not include proof of delivery for the specific items billed and the Plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that suppliers must provide proof of delivery for billed items. We looked at the file and Medicare rules. Although a delivery ticket was submitted, this ticket does not support proof of delivery for the specific items billed on this claim. Based on this information, we decided that Medicare rules for coverage of lower extremity orthoses have not been met. Therefore, we decided that the Plan does not have to pay for lower extremity orthoses provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 6, 2021, to January 8, 2021.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that care could have been provided at a lower level.
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 the 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 that the record shows 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 the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 6, 2021, to January 8, 2021.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from September 4, 2020, to September 5, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you were not in the frame of mind to accept or deny charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for emergency care. You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided from September 4, 2020, to September 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Personal Protective Equipment (PPE) (D1999) provided October 29, 2020, November 3, 2020, and November 17, 2020.
You asked the Plan to pay for the PPE. You say that it is unfair to charge for the PPE. The Plan denied your request. The Plan says the item is 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 apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the Personal Protective Equipment (PPE) (D1999) provided October 29, 2020, November 3, 2020, and November 17, 2020.