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

We decided that the Plan does not have to pre-approve sacroiliac joint injection.
You asked the Plan to pre-approve sacroiliac joint injection. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered for certain indications. 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 sacroiliac joint injection. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of low back pain related to sacroiliitis. The enrollee has undergone a previous sacroiliac joint injection (SJI). The enrollee states the injection only gave 15-20% relief for about 2 weeks. In this case, the previous sacroiliac injection only provided 15-20% relief for about 2 weeks. The review has determined that this enrollee has a diagnosis and/or symptoms that meet the Medicare criteria for coverage of an SIJ, however, it is not medically necessary and reasonable for this enrollee to have an SIJ as requested, as there was no documentation of pain relief of at least 50% for 6 weeks from the previous SIJ injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B injection provided on October 28, 2019 and November 25, 2019.You asked the Plan to waive the coinsurance for the Medicare Part B injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a Medicare Part B injection on the dates of service at issue in this appeal. The Plan states the correct coinsurance has applied per your contract with the Plan.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 10% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows you received Medicare Part B injections on October 28, 2019 and November 25, 2019. You have been asked to pay a 10% coinsurance for each of the Medicare Part B injections, totaling $363.92 for the October 28, 2019 date of service and $357.98 for the November 25, 2019 date of service. The Medicare Part B injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe Medicare Part B injection provided on October 28, 2019 and November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The referring provider 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 forthe medical services provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from October 22, 2019
through November 2, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the two admissions appear to be unrelated directly, however, protonix and awaiting active
bleeding is the appropriate course following the first admission. Isolating the second admission presentation,
severe anemia low baseline, history of significant CAD, and ongoing weakness/lethargy which was slow to
resolve in the prior admission suggested this patient warranted at least a two-midnight stay for monitoring, IV
Protonix, and packed red blood cell treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for inpatient hospital care provided to the enrollee from October 22, 2019 through November 2,
2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on November 24,
2019.
You asked the Plan to waive the copayment for inpatient hospital 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).
Review of the file show that you received inpatient hospital care on November 24, 2019. You are asked to pay
a $285 copayment for the inpatient hospital care. 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 on November 24, 2019.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for the inpatient hospital care provided up to June 7, 2019 at 2:34pm. We also decided that the Plan does not have to pay for the inpatient hospital care provided after 2:34pm on June 7, 2019 to June 11, 2019. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pay for the inpatient hospital care provided
June 7, 2019 to June 11, 2019. Our reviewer says that the enrollee was declared stable for transfer to an
in-network hospital on June 7, 2019 at 2:34pm as at that time his blood pressure was normal, and his oxygen saturation was 100% on supplemental oxygen. Any care provided after 2:34pm on June 7, 2019 is post-stabilization care and is not covered unless pre-authorized by the health plan. The inpatient hospital care provided on June 7, 2019 after 2:34 pm through June 11, 2019 was not pre-authorized by the health plan.
We looked at this doctor's review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have been partially met. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided up to June 7, 2019 at 2:34pm. We also decided that the Plan does not have to pay for the inpatient hospital care provided after 2:34pm on June 7, 2019 to June 11, 2019.
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 copayment for cardiac rehabilitation provided from July 1, 2019 through July 31, 2019.You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you would not have attended rehab if you knew the cost.The Plan denied your request. The Plan says the copayments 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 $50 copayment for Medicare-covered cardiac rehabilitation and intensive cardiac rehabilitation services.You have been asked to pay a $50 copayment for each cardiac rehabilitation visit. The total amount you owe is $550 ($50/visit x 11 visits = $550). Cardiac rehabilitation falls within the "Cardiac rehabilitation 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 cardiac rehabilitation provided from July 1, 2019 through July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you called the Plan and were told that the orthotics would be covered. You say that you were not told by the Plan representative that the inserts would only be covered if you are diabetic. You asked the Plan to provide coverage for the inserts since you say you were unaware that they would not be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided on March 14, 2019.You asked the Plan to pay for non-emergent ambulance services. You say that the transfer of care to a facility was necessary for medical management.The Plan denied your request. The Plan says the Medicare rules have not been met.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. You were transferred to your surgeon's office for an open wound per the order of your physician. Per the trip report provided, you were able to sit in a wheelchair to be transported. You received and signed an acknowledgement that you would be responsible for the services provided to you by the ambulance provider if your insurer did not pay in full or in part.Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided on March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from May 1, 2017 through May 30, 2017, by a non-Medicare provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services were not authorized because this provider is non-certified by Medicare as a provider. The Plan states the member's primary care physician (PCP) did not refer for 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 services are not authorized because you are not certified by Medicare as a provider, do not work with the Plan, and the member self-directed for services. The member's PCP did not refer for services. The health plan requires utilization of Medicare-certified network providers, and requires authorization for non-urgent services. No urgent or emergency situation, has been documented. There is no network deficiency for these services and alternate network providers were found. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from May 1, 2017 through May 30, 2017, by a non-Medicare provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 23, 2019 through September 26, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 23, 2019 through September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says further visits will need updated clinical information to make sure continued services are needed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has already had physical therapy on a long term basis and is a long-term care resident and would have caregiver assistance available. Physical therapy provided in excess of what is medically necessary may promote dependence on therapy provided treatments rather than a regularly performed home exercise program. A daily home exercise program with caregiver assistance would best meet this enrollee's needs. The additional visits approved should be adequate in terms of completing caregiver training and establishing an effective home exercise/maintenance program with revision if necessary. A reassessment after completing the treatments that were authorized would be expected before requesting additional therapy. For these reasons, the remaining therapy requested is not 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you have pain in your hip, knees, lower back and neck when you have been walking or standing due to a misalignment from your leg length discrepancy. You stated that you have been vigilant with your physical therapy program and were referred to a podiatrist to prevent further distress. The podiatrist stated that the requested orthotics are the best solution for preventing further physical problems down the road. You say that you are an active person and want to remain that way so you can stay physically and emotionally healthy. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe seat lift mechanism provided on December 5, 2019.You asked the Plan to pay forthe seat lift mechanism. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the item received is not a covered benefit.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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the item provided in this case. Since there is no physician order for the item received, a valid diagnosis has not been provided to support that the item received was necessary. Therefore, we decided that the Plan does not have to pay forthe seat lift mechanism provided on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on September 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for the surgery services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says prior authorization was not received before provided 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 surgery services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 23, 2019 through August 26, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there were insufficient objective findings suggestive of complicated acute illness which might have warranted at least a two-midnight stay in the acute care hospital, according to the provided records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from August 23, 2019 through August 26, 2019.