Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder elbow wrist hand orthosis provided on August 20, 2020.You asked the Plan to pay forthe shoulder elbow wrist hand orthosis. 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 does not contain a valid proof of delivery for the supplies provided in this case. The DeliveryTicket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe shoulder elbow wrist hand orthosis provided on August 20, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on September 1, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the copayments waived during the pandemic should include this $70 copayment. You say that you are disputing the amount. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $70 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan says that only copayments for in-network primary care visits, outpatient behavioral health visits and telehealth visits are being waived. 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 x-ray provided on September 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from May 14, 2020 to June 9, 2020.You asked the Plan to pay forthe SNF care. You say that the SNF care provided from May 14, 2020 to June 9, 2020 was medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the SNF care provided from May 14, 2020 to June 9, 2020.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with HIV, NPH, hyperlipidemia, bipolar disorder, bronchitis and GERD. 
From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was monitoredfor falls. Her lungs were clear. Regarding rehabilitation services, the enrollee received speech therapy, physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a contact guard assist level for functional mobility.   There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from May 14, 2020 to June 9, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transport services provided on July 25, 2020.You asked the Plan to pay forthe transport services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plan does not have to pay forthe transport services provided on July 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from April 3, 2020 to April 7, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient hospital care provided from April 3, 2020 to April 7, 2020 was medically necessary.The Plan denied your request. The Plan says that the inpatient hospital care provided from April 3, 2020 to April 7, 2020 was 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 inpatient hospital care provided from April 3, 2020 to April 7, 2020 was medically necessary. Our physician reviewer found the review indicates that the enrollee was transferred to the ER on April 3, 2020 from her dialysis center for the evaluation of cough, shortness of breath, and fever. She was evaluated and admitted and received airborne and contact precautions. She received hemodialysis and results revealed she was COVID-19 positive. She had been initially placed on Prednisone and was receiving nebulizer treatments. Her condition stabilized and improved and she was discharged home April 7, 2020 with isolation instructions and outpatient follow-up including continued hemodialysis.The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from April 3, 2020 to April 7, 2020.

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: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 30, 2020, to July 3, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient hospital care provided from June 30, 2020,to July 3, 2020,was medically necessary.The Plan denied your request. The Plan says that the inpatient hospital care provided from June 30, 2020,to July 3, 2020,was 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 inpatient hospital care provided from June 30, 2020,to July 3, 2020,was medically necessary. Our physician reviewer found the enrollee underwent an ampullectomy surgery on June 30, 2020,approved by the Plan. The enrollee's recovery was complicatedby post ERCP pancreatitis, and he was admitted through the emergency department and discharged on July 3, 2020.This enrollee was very ill with several potentially life threatening diagnoses. Based on the documentation provided, the hospitalization was medically reasonable and would be reasonably expected to stay 2 or more midnights. The enrollee was at risk for decompensation.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 forthe acute inpatient hospital care provided from June 30, 2020,to July 3, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on September 8, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this provider is
not a preferred provider with the vision network that is contracted to provide the supplemental benefit for your
plan.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers
these services when provided by a preferred vision provider.

We looked at the file and the Plan's rules. The file shows the requested provider in this case is not a network
provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eye
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction
provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 6, 2020 by an out of network provider.

You asked the Plan to pay for the physician services. You say that the physician's office told you they take your insurance so it is not your fault. The Plan denied your request. The Plan says you did not request 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 Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at 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 for the physician services provided on October 6, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve the requested services. You say that proton therapy has a superb ability to decrease toxicity exposure. The Plan denied your request. The Plan says proton beam therapy for breast cancer is investigational.
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 requested services. Our physician reviewer found that routine use of proton therapy for breast cancer is not an accepted standard of care. Intensity-modulated radiation therapy (IMRT) that is photon based is designed to facilitate normal tissue sparing. While proton therapy can be used, the case file does not provide a plausible rationale for the need of proton therapy over conventional radiation and/or IMRT in this enrollee. Therefore, the requested treatment is not considered medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe post stabilization care provided from June 22, 2020 to June 23, 2020.You asked the Plan to pay forthe post stabilization care. You say that the post stabilization care provided from June 22, 2020 to June 23, 2020 was medically necessary.The Plan denied your request. The Plan says the post stabilization care provided from June 22, 2020 to June 23, 2020 was not medically necessary.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 the post stabilization care. Our reviewer says that the post stabilization care provided from June 22, 2020 to June 23, 2020 was not medically necessary. Our physician reviewer found the review indicates that all inpatient care provided after 10:01 am on 06/22/20 through 6:30 pm on 06/23/20 was not needed on an emergent basis. The enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility. The post-stabilization care services at the non-Plan facility after 10:01am June 22, 2020 to June 23, 2020 were not medically necessary and reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee wasnot 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 the post stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization care provided from June 22, 2020 to June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PENS device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's function is severely limited due to pain. The Plan denied your request. The Plan says the device does not fit the definition of an implanted stimulator.
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulators are only covered under certain medical indications. We looked at the file and Medicare rules. The file shows that a device was requested for the enrollee's knee pain. The requested device is not a stimulator that is implanted in the enrollee's spinal cord or nervous system. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a PENS device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services provided to the enrollee from July 1, 2019,
to July 15, 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 the services provided are inclusive under services approved and paid to the attending
Oncologist. The Plan states that as the chemotherapy and infusion pump and supplies were provided during the
visit on July 1, 2019, and July 15, 2019, by the Plan and the Oncologist, the non-participating laboratory claims
are bundled into the claim submitted by the Oncologist and would not be paid separately to the nonparticipating
lab. In this case the lab should be billing the Oncologist for this claim. The Plan says that
Medicare's payment for the administration of the drug or biological billed to the mac will also include payment
for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin
administration of the drug or biological that the patient takes home to complete the infusion, is not separately
billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(a) and (b)
incident to benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and in the correct circumstance. In this case the
services billed are bundled into a separate claim by the Oncologist and cannot be paid separately by the Plan.
This claim should be submitted to the treating Oncologist per the Medicare billing guidelines. Therefore, we
decided that the Plan does not have to pay for infusion services provided to the enrollee from July 1, 2019, to
July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve inpatient rehabilitation stay. You say that other providers are not equipped to help the enrollee. 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 be treated by an in-network 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 care that cannot be provided by network providers. 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 an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the esophagoscopy provided. 

You asked the Plan to waive the copayment for the esophagoscopy. You say that the bill was supposed to be paid for by the VA. You say that the enrollee shouldn't be responsible for the billing office's mistake.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).The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.


The enrollee has been asked to pay a $275 copayment for the esophagoscopy. The esophagoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the esophagoscopy provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH care is medically necessary and appropriate for the enrollee who is stable and ready for discharge. You say that the enrollee requires prolonged and intensive skilled services that are not available at a lower level of care.The Plandenied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current hospital level of care setting.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 short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. There are not services at the LTACH which the enrollee requires that are not available at the healthcare setting being offered by the Plan. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinfusion supplies provided to the enrollee on August 6, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe requested documentation/medical records to develop the claim were not received timely.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 HCPCS code A4222 is "Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)."We find that HCPCS code A4222 is not supported in the medical record. Specifically, payment for this code is bundled into payment for the provider's visit. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forinfusion supplies provided to the enrollee on August 6, 2019.