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

We decided that the Plan does not have to pay for home health services (S9122) provided from April 23, 2019 to May 9, 2019 by a provider that does not participate in Medicare.
You asked the Plan to pay for home health services. You say that these services were medically necessary. The Plan denied your request. The Plan says the provider for these services is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The provider the enrollee received these services from is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S9122) provided from April 23, 2019 to May 9, 2019 by a provider that does not participate in Medicare.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage A0425) provided September 28, 2019.
You asked the Plan to pay for the ambulance services. You say that please see all supporting documentation and reprocess for payment. The Plan denied your request. The Plan says this service was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the records do not support that other means of transport were contraindicated. The records do not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The records do not support that the ambulance transport on 09/28/2019 was medically reasonable and necessary for the patient. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage A0425) provided September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on January 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 for the medical services provided to the enrollee by an out-of-network provider
on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hysteroscopy provided on January 8, 2020.
You asked the Plan to waive the copayment for the hysteroscopy. You say that you had a procedure done at the hospital and that you did not go to the emergency room. You say you should not be getting a bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). Your contract with the Plan clearly says that you must pay a $200 copayment for each visit to an ambulatory surgical center. You have been asked to pay a $200 copayment for the hysteroscopy. The hysteroscopy falls within "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 hysteroscopy provided on January 8, 2020.
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 you would like reconsideration because you will not be taken care of properly within a nursing home. The Plan denied your request. The Plan says you can safely receive the services you need in a lower level of care.
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 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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Your rehab needs can be met at a lower intensity 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 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for an injection. We decided that the Plan does not have to reduce the copayment for outpatient hospital services. You asked the Plan to reduce the coinsurance for an injection and copayment for outpatient hospital services. You say that you cannot afford such a high coinsurance. The Plan says that the correct cost-sharing amounts have been applied.We decided that the Plan has to reduce the coinsurance for an injection.Therefore, we decided that the Plan has to reduce the coinsurance foran injection. The total allowed amount is $1,116.94. The total coinsurance amount is $223.39 ($1,116.94 x 20% = $223.39).We also decided that the Plan does not have to reduce the copayment for outpatient hospital services. Therefore, we decided that the Plan does not have to reduce the copayment for outpatient hospital services.The total amount you are being asked to pay for outpatient hospital services is $42.30.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 21, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay for this since you were not given an option. The Plan denied your request. The Plan says that the claim processed 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 $250 copayment for each Medicare-covered trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered trip 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 ambulance transport provided on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional chiropractic services.
You asked the Plan to pre-approve additional services. You say that you cannot walk without being adjusted.
The Plan denied your request. The Plan says your benefit maximum has been reached.
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 Plan offers an additional chiropractic benefit
that exceeds Medicare coverage. For that reason, the Plan's rules apply in this case.
The records show that you have used 12 routine chiropractic visits. Based on this information, we decided that
you have exhausted the Plan maximum benefit for coverage of routine chiropractic services. Therefore, we
decided that the Plan does not have to pre-approve additional chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) provided on February 12, 2020 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that there are no copays for in or out-of-network with no maximum amount.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.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.Review of the file show that you received a periodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) on February 12, 2020 by an out-of-network provider. Your EOC states, providers are paid based on Maximum Allowable Charge (MAC).  For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider.Therefore, we decided that the Plan does not have to pay forperiodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) provided on February 12, 2020 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram and biopsy (A4648, 77065) provided January 3, 2020.
You asked the Plan to waive the coinsurance for the mammogram and biopsy. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing has been applied.
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 5% coinsurance for Outpatient Hospital Radiology services. You have been asked to pay a 5% coinsurance for the mammogram and biopsy. The mammogram and biopsy fall within the Outpatient Hospital Radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram and biopsy (A4648, 77065) provided January 3, 2020.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown -porcelain/ceramic (D2740) provided on December 30, 2019.You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Your EOC states, the Plan covers one (1) exam and cleaning every six (6) months, and one (1) set of dental X-rays every year (bite-wing X-rays).Therefore, we decided that the Plan does not have to pay for crown -porcelain/ceramic (D2740) provided on December 30, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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 the enrollee presented to the acute hospital on 06/01/2020 with osteomyelitis of the left lower extremity and foot. She underwent a left below-the-knee amputation on 06/01/2020. She is weak and deconditioned with shortness of breath with minimal activity. She is working with physical and occupational therapy though she fatigues quickly with low endurance. She is unable to stand or walk and is moderate to maximum assist for transfers and activities of daily living. There is no report of any ongoing medical instability post-operatively. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carac (fluorouracil) cream.You asked the Plan to pre-approve Carac cream. You say that this medication is more beneficial for the enrollee's condition.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Carac (fluorouracil) cream.Benefits for Carac cream may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on February 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you forthe portable oxygen concentrator purchased on December 23, 2019.You asked the Plan to reimburse you forthe portableoxygen concentrator. You say that you were told you could purchase the concentrator out-of-network with a 45% coinsurance and be reimbursed 55%. The Plan denied your request. The Plan says that purchased oxygen equipment is not covered.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 enrolleespay 45% coinsurance for out of network durable medical equipment. Medicare does not cover purchased oxygen equipmenthowever; the record shows you were told you could purchase the oxygen concentrator in network or out of network.Therefore, we decided that the Plan has to reimburse youthe 55%coinsurance forthe portable oxygen concentrator purchased out of network on December 23, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forlodging costs (S9975) accrued on January 21, 2020 through January 22, 2020.You asked the Plan to pay forthe lodging costs. You say that you would like reimbursement because the provider is 4.5 hours away from your home.The Plan denied your request. The Plan says this service is not covered under the Transplant Travel and Lodging benefit.The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.  The Plan contract includes rules for an inpatient hospital benefit for transplant travel and lodging. We looked at the file and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the lodging costs have not been met. Specifically, the transplant travel and lodging is an inpatient hospital benefit. The record indicates that you received outpatient, follow-up services.Additionally, the record indicates that you were informed that this code would not be a covered benefit at the time of service. Therefore, we decided that the Plan does not have to pay forlodging costs (S9975) accrued on January 21, 2020 through January 22, 2020.