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

We decided that the Plan does not have to pay for LTACH services.
You asked the Plan to pay for the LTACH services. You say that the requested transfer to a LTACH is medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the records show the enrollee has not completed the full course in the hospital.
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 pay for 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 pay for LTACH services
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after June 14, 2021.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that you do not require daily skilled services on an inpatient basis at the SNF level of care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 14, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after June 14, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis provided on March 22, 2021, by an OON provider.
You asked the Plan to pay more for the prophylaxis. You say that per your dental rider this service is covered in full regardless of the provider's network status. The Plan denied your request. The Plan says your dentist is not part of the Plan's network and charges more than the Plan allowed amount for the service provided to you.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more
for the prophylaxis provided on March 22, 2021, by an OON provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on October 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on October
13, 2020 by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need the SNF care so you can get stronger, learn how to be safer within your home or if and when you get transferred to an assisted living facility. You state all treating providers, social workers at the independent living facility are all recommending the SNF care and treatment because they do not feel you are safe in the current living situation. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your
care needs, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the OON provider on December 8, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the OON provider on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the
out of network (OON) provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON)
provider on February 15, 2021
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 LTACH care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visits provided from January 23, 2020, through March 18, 2021.
You asked the Plan to reduce the copayment for the office visits. You say that you can only pay a $10 copayment per visit for treatment. The Plan denied your request. The Plan says the 2019 visits will be covered at a $10 copayment. The remaining copayments of $50 and $45 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 2020 contract with the Plan clearly says that you must pay a $50 copayment for each specialist or any other physician or other health care professional visit for Medicare-covered benefits in a specialist setting. Your 2021 contract with the Plan clearly says that you must pay a $45 copayment for each specialist or any other physician or other health care professional visit for Medicare-covered benefits in a specialist setting. You have been asked to pay a $50 copayment for each office visit provided in 2020. The evaluation and management service provided on December 17, 2020 only applied $26.46, which is less than the standard $50 copayment. You have also been asked to pay a $45 copayment for each office visit in 2021. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The office visits were provided by a specialist.
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 copayment for the office visits provided from January 23, 2020, through March 18, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test coded G0483 provided on December 17, 2020.
You asked the Plan to pay for the drug test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted does not support 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test coded G0483 provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial preventive physical examination provided on March 2, 2021.
You asked the Plan to pay for initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment (G0402). You say that you did not use this benefit before. The Plan denied your request. The Plan says a review of the claims shows you received this same service on December 18, 2018.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of a Welcome to Medicare preventative visit once. Based on review of the file, you already received this service. Therefore, we decided that the Plan does not have to pay for the initial preventive physical examination provided on March 2, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for outpatient wound care (97602) provided on January 25, 2021, by an out of network (OON) provider.
You asked the Plan to pay for outpatient wound care. You say that the services were medically necessary. The Plan denied your request. The Plan says that services were provided by an out-of-network provider without prior authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to forward the correct EOC. We are unable to determine if the contract criteria have been applied appropriately. Please note, this documentation has been requested and was not received. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated with contractual evidence so we must find in your favor. Therefore, we decided that the Plan has to pay for outpatient wound care (97602) provided on January 25, 2021, by an out of network (OON) provider.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits.
You asked the Plan to pre-approve home health care. You say that you can only move about 20 feet with a walker and cannot cook or bathe yourself. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you have been taught a home exercise program and have been compliant with it with no other home care therapy services needed at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found you are noted to be consistently ambulating more than 100 feet. You do not have documented skilled physical therapy needs. As such, the requested home health physical therapy services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the wound care supplies provided on February 17, 2021.
You asked the Plan to pay for gauze (A6402). You say that the gauze was ordered by your doctor without your knowledge and you cannot afford the payment. The Plan denied your request. The Plan says that if the supplies are delivered you are responsible for payment.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for gauze (A6402) by a contract provider. The file does not show that the Plan provided notice that gauze (A6402) would not be covered. Under Medicare rules, this means gauze (A6402) is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the wound care supplies provided on February 17, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to waive the deductible for the home health services provided from December 31,
2020, to January 18, 2021.
You asked the Plan to waive the deductible for the home health services. You say that the claim was not paid in
its entirety. The Plan denied your request. The Plan says that you have been asked to pay the correct costsharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for at member's home for out-of-network
home health care.
The Plan says you must pay a total of $540 towards the $1,000 deductible for the home health services. Based
on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the home health
services on each date of service. The record shows you do not have a deductible for 2021. Therefore, we
decided that the Plan has to waive the deductible for the home health services provided from December 31,
2020, to January 18, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from July 18, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that you are requesting an additional seven (7) days because the enrollee is unable to discharge home at this time with their daughter. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care provided to the enrollee from July 18, 2021, forward.