Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for residential care facility services provided on
August 8, 2019 through August 23, 2019.
You asked the Plan to reimburse you for the residential care facility services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the services you
received did not include any skilled therapy or medical services.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the residential care facility services have not been met. Specifically, the services you received at
this facility are considered custodial care which is not a covered benefit. Therefore, we decided that the Plan
does not have to reimburse you for residential care facility services provided on August 8, 2019 through
August 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ulnar nerve neuroplasty (64718).
You asked the Plan to pre-approve the ulnar nerve neuroplasty. You say that you have been in pain and had
numbness in the arm for over a year. The Plan denied your request. The Plan says this service is not medically
necessary as the nerve conduction studies showed normal results.
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 ulnar nerve neuroplasty. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the EMG does not show any issues or abnormalities with the ulnar nerve.
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 ulnar nerve neuroplasty have not been met. Therefore, we decided that the
Plan does not have to pre-approve an ulnar nerve neuroplasty (64718).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device for the enrollee.
You asked the Plan to pre-approve a CPM. You say that the CPM is medically necessary to help this patient improve early postoperative range-of-motion. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methadone for the enrollee.
You asked the Plan to pre-approve Methadone. You say that this is medically necessary. The Plan denied your request. The Plan says that this medication 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 Methadone for the enrollee.
Benefits for Methadone 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital psychiatric care.You asked the Plan to pre-approveinpatient hospital psychiatric care. You say that the enrollee continues to present with multiple issues.The Plan denied your request. The Plan says the denial of authorization for inpatient hospital psychiatric care is correct.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient hospital psychiatric care. Our reviewer says that the enrollee doesnot meet the Medicare criteria for continued inpatient hospital psychiatric care. Our physician reviewer found based upon review of the records provided it is not expected that this enrollee will improve in a reasonable period of time as he was not showing any dangerousness to self or others, no auditory or visual hallucinations, and no aggressive behaviors. The enrollee did not want to go to an assisted living facility. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The Plan's denial of continued inpatient psychiatric services appears appropriate. It does not appear that active treatment is taking place. It does not appear that the services are reasonable expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. There is no individualized treatment plan in the record, however the entire record is not present. It appears that services are supervised and evaluated by a physician.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital psychiatric care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient hospital psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 4, 2019 to September 6, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the
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 $410
copayment per day for days 1-4 for inpatient hospital care.
You had an inpatient hospital stay from September 4, 2019 to September 6, 2019. Therefore, you are
responsible to pay a $410 copayment for days 1-2 (September 4, 2019 to September 5, 2019). The total amount
you owe is: $410 (copayment) x 2 (inpatient days) = $820.00.
You have been asked to pay the total copayment amount of $820.00 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from September 4, 2019 to September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71046) provided on August 5, 2019 by out of network provider, 
You asked the Plan to pay for an x-ray. You say that the claim was denied for no authorization. Medical records were supplied as the procedure was medically necessary. The Plan denied your request. The Plan says members are required to receive all care from network providers at network facilities unless that care is urgent/emergent or not available in-network. All care must be medically necessary, ordered by a network provider, and authorized by the Plan prior to any care being provided.
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 x-ray (71046) provided on August 5, 2019 by out of network provider,
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 19, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you say you are on a fixed income and cannot afford the 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 $165 copayment for Medicare-covered ambulance services.  
 
You have been asked to pay a $165 copayment for the ambulance ride. The ambulance ride 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 for the ambulance ride provided on September 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 27, 2018 to February 15, 2018.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a HIPPS code and an appropriate Q code were missing on the claim for the billed dates of service.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted is missing the required HIPPS and Q codes. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 27, 2018 to February 15, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural injections for pain management (62321). 
 
You asked the Plan to pre-approve epidural injections for pain management. 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 follows Medicare rules. Medicare rules say that if a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same method, technique or medication to the same level will be considered not medically 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 epidural injections for pain management. Our reviewer says that the service is not medically necessary. Our physician reviewer found you did not achieve greater than 50% pain improvement from the prior two epidural steroid injections. It is not medically reasonable or necessary to repeat injections that did not produce significant relief.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural injections for pain management have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural injections for pain management (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder/arm orthosis, knee orthoses and sleeves provided to the enrollee on October 7, 2019.
You asked the Plan to pay for these items. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder/arm orthosis, knee orthoses and sleeves provided to the enrollee on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic laboratory services provided on August 9, 2019 by out of network provider.You asked the Plan to pay for diagnostic laboratory services. You say that you are requesting reconsideration providing full reimbursement against the patient's in-network benefits for the denied services. If the Plan does not fully cover the cost of this test, the beneficiary may be held financially responsible for this balance.The Plan denied your request. The Plan says the non-urgent services are not authorized because provider is a non-network provider with the member's health plan. Another non-network provider with the member's health plan physician referred the member for services.This takes precedence over the claim system denial. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 diagnostic laboratory services provided on August 9, 2019 by out of network provider.
Please remember that you signed a Waiver of Liability in which you agreed not to bill enrollee for these services. This Waiver does not, however, deny your right to seek further appeal from an Administrative Law Judge
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 12, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
charged a copayment because this was a follow-up appointment to review your test results. 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 $35
copayment for each Medicare-covered specialist visit.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there
is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a
procedure.
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 specialist office visit provided on September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
You asked the Plan to pre-approve Magnetic Resonance Imaging (MRI) test. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can receive this test at an in-network radiology facility.
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 to be provided by the out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgical services provided on June 14, 2019.
You asked the Plan to waive the coinsurance for the outpatient services. You say that the services should have
been done on an inpatient basis so the inpatient copayment would be applied. The Plan denied your request.
The Plan says criteria for inpatient admission was not met. The correct cost sharing for outpatient hospital
services was 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 20%
coinsurance for Outpatient Hospital Services.
You have been asked to pay a 20% coinsurance for the outpatient services. The services fall within the
Outpatient Hospital 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 coinsurance for outpatient
surgical services provided on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for form fitting conductive garment for delivery of tens or nmes
(with conductive fibers separated from the patient's skin by layers of fabric) (CPT Code E0731) provided to the
enrollee on March 26, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. There is insufficient published
clinical evidence to establish that treatment with other electro-magnetic devices such as transcutaneous
electrical stimulation devices (TENS), neuromuscular stimulators (NMES), functional electrical stimulators
(FES), light treatment devices (any type), infrared treatment devices (any type), etc. (not all-inclusive), singly
or in any combination, meet the requirements to be considered reasonable and necessary for the treatment of
osteoarthritis. Claims for these items will be denied as not reasonable and necessary. You can find this
Medicare guidance in the Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators
(TENS) (L33802); Medicare Benefit Policy Manual Chapter 15 Covered Medical and Other Health Services.
Therefore, we decided that the Plan does not have to pay for form fitting conductive garment for delivery of
tens or nmes (with conductive fibers separated from the patient's skin by layers of fabric) (CPT Code E0731)
provided to the enrollee on March 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 20, 2019 through March 25, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were initially hospitalized for pneumonia on March 8, 2019 to March 12, 2019 and was charged $1400 for your hospital stay. You state that your condition got worse and was once again admitted for pneumonia on March 20, 2019 through March 25, 2019 and charged another $1400. You state that the second hospital stay should be considered a continuation of the first and the second charge of $1400 should be dismissed. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted to an in-network provider on March 20, 2019 and discharged on March 25, 2019. You were asked to pay a $350 copayment per day from March 20, 2019 through March 23, 2019, days 1-4 of your inpatient hospital care. There were no copayment charges from March 24, 2019, day 5 of your inpatient hospital care until your day of discharge March 25, 2019. Per your contract there is a $350 copayment per day required for days 1-4. 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 March 20, 2019 through March 25, 2019 provided by an in-network provider.