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

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are on dialysis 
and need to go to a doctor 3 times a week. The Plan denied your request. The Plan says the requested trips 
exceed the allowable limits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have received 
coverage for 40 one-way routine transportation trips in the 2021 calendar year. This means that your benefit for 
routine transportation services has been exhausted. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care.

You asked the Plan to pay for hospital care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member will do better in an inpatient 
rehabilitation facility, where his family will have the ability to visit him due to the fact that the member suffers 
from dementia. The Plan denied your request. The Plan says that there is no evidence that the enrollee needs 
specialized training, staff nor equipment at an IRF. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a left tib-fib 
fracture after a motor vehicle collision. Your medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care supplies.

You asked the Plan to waive the copayment for the wound care supplies. You say that you do not think you should be liable for the coinsurance. The Plan denied your request. The Plan says you were charged the coinsurance 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 20% coinsurance for Durable Medical Equipment.

You have been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies fall within the Durable Medical Equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound care supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
February 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that please review the progress note to substantiate 
service as medically necessary. Reconsider for payment because this enrollee was under the doctor's care. The 
Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 skilled nursing facility (SNF) services 
provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care, per day (99220).

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 is not payable as the claim was submitted untimely.

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 this service was not filed. 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 for the initial observation care, per day (99220).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to reprocess the copayment for the ambulance services.

You asked the Plan to reprocess the copayment for the ambulance services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says that the copayment has processed correctly.

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 $250 copayment for ambulance services. 

The Plan says you must pay a $379.29 cost share for the ambulance services. Based on the Plan contract, however, you cannot be asked to pay more than a $250 copayment for the ambulance services. Therefore, we decided that the Plan has to reprocess the copayment for the ambulance.

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 pre-approve Vertiflex Superion device placement surgery for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that you recommend this minimally invasive 
procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion 
procedure. The Plan denied your request. The Plan says that there are not enough studies to show that use of 
the Vertiflex Superion device is better than regular spine surgery for your problem. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services provided on July 
14, 2020 and August 1, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the electroencephalogram services. 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 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 electroencephalogram (EEG) services 
provided on July 14, 2020 and August 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation 
setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to 
pay for the drug testing rendered on April 10, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the admission 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 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 these services. Our reviewer says that the admission is medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 infection. The physical therapy note states he needs assistance with walking, standing up, and returning to bed. He has no skilled nursing needs. He has skilled therapy needs and requires skilled therapy on a daily basis. As a practical matter, the enrollee requires the necessary services on an inpatient basis at the SNF 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 these services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission.

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 pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 based on the documentation provided, the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for CoViD-19. The enrollee was intubated twice and subsequently received a tracheotomy. The enrollee appears to be undergoing ventilator weaning under the supervision of a pulmonary critical care specialist. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation and panoramic x-ray.

You asked the Plan to pay for the detailed and extensive oral evaluation and panoramic x-ray. You say that you feel that these services should be covered by your medical insurance. The Plan denied your request. The Plan says these services are not covered benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the detailed and extensive oral evaluation and panoramic x-ray.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 80307 & G0483 are not supported in the medical record. Specifically, the record shows the specimen was obtained in the office setting (POS 11), however, the place of service listed on the claim is laboratory (POS 81). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy.

You asked the Plan to pay for medical nutrition therapy services. You say that you would like reconsideration because you are being counseled on your diet to correct your condition. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 based on the documentation provided, the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH following a stroke in the setting of stage IV colon cancer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter placement services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve catheter placement services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a network provider. 
 
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 
catheter placement services to be provided by an out of network (OON) provider.