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

We decided that the Plan does not have to pay for the services provided to the enrollee on March 29, 2019, by an out-of-network provider.
You asked the Plan to pay for the services. You say that services were necessary and they should be paid because the facility is responsible for obtaining authorization. The Plan denied your request. The Plan says non-participating providers must obtain prior authorization for all services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on March 29, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the x-ray or the CT scan provided on August 15, 2019 and September 26, 2019.
You asked the Plan to reduce the copayments for the x-ray and the CT scan. You say that you were not told that the x-ray and the CT scan were not covered and were not a part of your plan. 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 $90 copayment for basic radiological services at an in-network outpatient hospital and a $250 copayment for advanced imaging services at an in-network outpatient hospital. You have been asked to pay a $59.31, which is less than the standard copayment for the x-ray and a $250 copayment for the CT scan. The x-ray and the CT scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 reduce the copayments for the x-ray or the CT scan provided on August 15, 2019 and September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp injections.
You asked the Plan to pre-approve the Aranesp injections. You say that the enrollee meets all criteria and needs to be treated for anemia with this drug. The Plan denied your request. The Plan says the enrollee has inadequate iron stores for this drug to be effective.
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 the Aranesp injections. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found This patient with chronic kidney disease and a hemoglobin of <10 does not meet coverage criteria for Aranesp at this time due to a transferrin saturation of only 11% when coverage requires it be >20%. This patient requires a trial of iron to see if iron saturation can be improved as proper iron stores are required for safe and effective use of Aranesp. The service is not reasonable or medically necessary. 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 Aranesp injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp injections.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on August 12, 2019.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee fell and severely injured her hip and ankle. You also say that the claim was for an emergency transport and is not hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 ambulance service and ground mileage provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The PlansaysSNF level of care can be offered.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar puncture.
You asked the Plan to pre-approve a lumbar puncture. The Plan denied your request. The Plan says this is not medically necessary.
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 a lumbar puncture. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 76-year-old male with low back pain, lower extremity pain, paresthesias, weakness and imbalance. Based on the limited medical records provided, there is no documentation that the requested lumbar puncture is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar puncture have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar puncture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aid batteries.
You asked the Plan to pre-approve the hearing aid batteries. The Plan denied your request. The Plan says Hearing aids and their components are not covered by Medicare.
Medicare does not pay for hearing aids or related services.
We looked at the file, Medicare's rules and the Plan's rules. Medicare does not pay for hearing aids or related services. Therefore, we decided that the Plan does not have to pre-approve hearing aid batteries.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from September 14, 2019 to September 21, 2019.
You asked the Plan to pay for these services. You say that this should be covered as it is a valid procedure code according to Medicare. 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 home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Medicare. The plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from September 14, 2019 to September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided on June 11, 2019.
You asked the Plan to waive the copayment for the sacroiliac joint injection. You say that this was done at an outpatient center. You say that the Plan should pay. 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 an $18 copayment for services obtained from a specialist. Covered services include medically-necessary medical or surgical services furnished in a physician's office.
You have been asked to pay an $18 copayment for the sacroiliac joint injection. The sacroiliac joint injection falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show that the injection was received at a specialist's office. 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 sacroiliac joint injection provided on June 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve glatiramer 40mg/mL syringes.
You asked the Plan to pre-approve the glatiramer syringes. You say that this medication is medically necessary. The Plan denied your request. The Plan says this is a self-injected drug and is not covered by Medicare 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 glatiramer 40mg/mL syringes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from June 28, 2019 to September 16, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256) and lancet device (A4258) . You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from June 28, 2019 to September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for SNF care provided from May 1, 2019 through June 6, 2019.
You asked the Plan to waive the cost-share for SNF care. You say that you are appealing your cost-share responsibility for the services you received. 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). Because you were admitted for a total of 45 days, the $0 co-payment was applied for the first20 days while the $165 co-payment was applied for the remaining 25 days; cost-sharing for 20days was applied on the first claim, while the cost-sharing for the remaining 5 days was applied on the second claim. This totaled to an amount of $3,300.00 for the first 20 days while an amount of $825.00 was applied for the remaining 5 days. However, this cost-sharing amount is included as part of your overall maximum out-of-pocket (MOOP)
calculations. Your plan has a MOOP amount of $5,600 for the 2019 plan year. It was noted that the skilled nursing stay is the catalyst for reaching the MOOP limit, but the threshold was reached during your stay. Therefore, a new claim 191121962417 was created to reprocess the second appeal claim, adjusting the cost-sharing amount to reflect this. Payment was issued to the provider on November 21, 2019. 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 cost-share for SNF care provided from May 1, 2019 through June 6, 2019.
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 enrollee would have the best chance of recovery in the LTACH. The Plan denied your request. The Plan says LTACH is not able to offer any advantage over the current facility.
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 patient is currently undergoing treatment at an ACH, having been admitted with a stroke. The hospitalization was complicated by GI bleeding, an AV fistula infection and a DVT. The enrollee is receiving anticoagulation, her routine hemodialysis and rehabilitative services. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 15, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 28, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveservices with an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-network.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by thePlan or through arrangements made by the Plan.The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services.Therefore, we decided that the Plan does not have to pre-approveservices with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on August 19, 2019.
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by this provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on August 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on March 20, 2019, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the provider is not aware of the patient's insurance. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 services provided to the enrollee on March 20, 2019, by an 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 August 12, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you believe the transfer to another hospital was not necessary and you should not be required to pay 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 $195 copayment for each one-way Medicare-covered ground trip. 
You have been asked to pay a $195 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 August 12, 2019.