Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the enrollee does not warrant skilled nursing facility services, as he has no skilled medical needs.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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications. The enrollee had stable vital signs and was treated for pneumonia. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist to contact guard assist level with functional mobility, including gait to 150 feet with a rolling walker. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit and EKG provided on August 30, 2019.You asked the Plan to waive the copayment forthe office visit and EKG. You say that you have never had to pay for this before . You say that you don't have the money to pay.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 $10 foreach covered visit or consultation in an outpatient location with your PCP or other primary care physician. $10 per day for Medicare-covered tests. You have been asked to pay a $10 copayment for the office visit and a $10 copayment for the EKG. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The EKG falls 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 waive the copayment forthe office visit and EKG provided on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on October 16, 2019.
You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $230 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on October 16, 2019. The record shows that you had only paid $122.52 toward the $230 deductible. Therefore, you are responsible to pay the deductible amount of $57.89. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $230 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on October 16, 2019. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for X-Ray examinations provided on
November 22, 2019.
You asked the Plan to pay for X-Rays. You say that you are appealing with medical records. The Plan denied
your request. The Plan says the denial of payment for these services is correct, because these services are not
covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for X-Ray examinations provided on November 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forInpatient hospital services provided August 12, 2018 to August 20, 2018.You asked the Plan to pay forthe inpatient services. You say that the claim was submitted timely and correct.The Plan denied your request. The Plan says the claim was initially submitted with incorrect dates of service. The correct claim was not submitted until after the timely filing period.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the inpatient services was not filed until December 18, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forInpatient hospital services provided August 12, 2018 to August 20, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on November 12, 2019.You asked the Plan to waive the copayment for the lumbar injection. You say that the procedure didn't work completely. You say that you shouldn't have to 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 Planclearly says that you must pay a $325 copayment for outpatient surgery.You have been asked to pay $295.05, which is less than the standard $325 copayment for the lumbar injection. The lumbar injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The lumbar injection is considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the lumbar injection provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe perfusionist services provided on October 30, 2019.You asked the Plan to pre-approvethe services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 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-approvethe perfusionist services provided on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided to the enrollee on October 1, 2019, and October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says care could have been provided at a lower level.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was a then 75-year-old female with recent stroke who admitted to the Emergency Room from Rehab on September 28, 2019, with near syncope episode and coffee ground emesis. She was evaluated and required two transfusions during this current stay. On dates of service October 1, 2019, and October 2, 2019, the enrollee had stable vital signs and labs stable. She underwent an EGD that showed duodenitis. Acute Kidney injury was resolving with intravenous fluids. There was no active bleeding, no pain, and she was eating and taking medications by mouth. The requested inpatient care could have been provided at a lower level. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided to the enrollee on October 1, 2019, and October 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 25, 2019.
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says a requested claim with a valid type of bill code is requested.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was not submitted with a valid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability.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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve the proton beam therapy. You say that the clinical information provided supports the need for the requested treatment. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the provider has a history of publications in peer-reviewed medical literature for the use of proton beam therapy in treatment of unresectable lung cancer. 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance and deductible applied tomedical services provided by provider on January 17, 2020.You asked the Plan to waive the coinsurance and deductible applied to the medical services provided by provider. You say that the scheduler at the doctor's office was advised that no prior authorization was necessary. You say that the day of the procedure, the doctor's office advised you that they received approval. You say that, when asked what number was called, the doctor's office advised that they used the number on the back of your insurance card.The Plan denied your request. The Plan says the cost sharing amounts have been appropriately applied to the services in dispute.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 there is a $250 yearly deductible for out-of-network services that must be paid before the plan will pay their share towards these services. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for physician/practitioner services provided in an out-of-network certified ambulatory surgical center or hospital outpatient department. You have been asked to pay $250 toward the cost of the medical services provided by provider on January 17, 2020. This amount applied to your yearly out-of-network deductible, which had not yet been met. You have also been asked to pay a 20% coinsurance for the medical services provided by provider on January 17, 2020. provider is an out-of-network provider, and the medical services in dispute fall within the physician/practitioner services provided in an out-of-network certified ambulatory surgical center or hospital outpatient department benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. These cost sharing amounts are 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 and deductible applied tomedical services provided by provider on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a spinal surgery (63046, 22551, 22845, 63075) provided on August 5, 2019.
You asked the Plan to pay for surgical assistant services. You say that you were told these services would be covered. The Plan denied your request. The Plan says this provider is not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a spinal surgery (63046, 22551, 22845, 63075) provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea male vacuum erection system (L2900).You asked the Plan to pre-approvea male vacuum erection system. You say that the requested item is medically necessary because the enrollee underwent radical prostatectomy due to presenting voiding dysfunction, urinary incontinence and erectile dysfunction.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea male vacuum erection system (L2900)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline and power elevating leg rests through the joystick (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313), for the enrollee.You asked the Plan to pre-approve the DME. You say that you are requesting review ofdenial of services.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that the member's strength is noted to be 5/5 in the right upper limb, and member is independent with feeding. This upper limb strength and function are therefore adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.Therefore, we decided that the Plan does not have to pre-approve Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline and power elevating leg rests through the joystick (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313), for the enrollee
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the physician depends on the hospital staff to verify eligibility and to obtain the proper authorization.The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.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 did not pre-approve the services 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 forthe medical services provided to the enrollee on November 11, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from October 7, 2019 to October 10, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $200 copayment per day for days 1-4 for inpatient hospital care.You had an inpatient hospital stay from October 7, 2019 to October 10, 2019. Therefore, you are responsible to pay a $200 copayment per each day. The total amount you owe is: $200 (copayment) x 3 (inpatient days) = $600.You have been asked to pay the total copayment amount of $600for an inpatient hospital stay. An inpatient hospital stay falls within the Medicare Part B prescriptiondrugs 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 foran inpatient hospital stay from October 7, 2019 to October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility careprovided on December 18, 2019 and December 20, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare 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 thePlan. The Plan did not pre-approve the servicesatissue. 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 subsequent nursing facility careprovided on December 18, 2019 and December 20, 2019.