Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for the eye exam and reimburse you up to $100 for the standard eyewear.
We decided that the Plan does not have to pay for the upgraded add-ons for your eyeglasses.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. Your EOC on page 123-124 says that one routine eye exam is
covered every year for a $0 copayment and that up to $100 is allowed toward routine eyewear. Therefore, the
eye exam should be paid in full, and $100 should be reimbursed toward the cost of the eye glasses. You are
only to be reimbursed $100 for the eyewear because your EOC states that you are responsible for any costs
above the $100 maximum for supplemental (i.e., routine) eyewear. Furthermore, the plan does not have to pay
for the upgraded add-ons for your eyeglasses because they are not covered according to Medicare rules.
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 10 skilled nursing and home health aide visits.
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration
because the member is elderly, has arthritis, and blacks out from time to time. The Plan denied your request.
The Plan says the provider notes do not show the member has a medical condition requiring treatment by a
skilled nurse.
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 the home health services. Our reviewer
says that the records do not show that skilled nursing services are required to effectively provide treatment,
care, and/or services in order to improve the member's condition, or to establish/perform a maintenance
program to maintain the patient's condition and/or prevent deterioration. Our physician reviewer found the
documentation does not reveal the member has complex wound care, new enteral feedings or other skilled
nursing need. The member has had teaching on disease and medication management and educated on safety.
The member does not require ongoing skilled nursing. There is no documentation that the member requires
skilled nursing or skilled therapy 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 the home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve 10 skilled nursing and home health aide visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on December
17, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you should not be charged
two separate copayments and should only owe one. 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). Your contract with the Plan clearly says that you must pay a $10
copayment for each lab services.
You received two laboratory services on December 17, 2019. Therefore, you are responsible to pay a $10
copayment per each laboratory service. The total amount you owe is: $20.
You have been asked to pay the total copayment amount of $20 for laboratory services. Laboratory services fall
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 for laboratory services provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tissue exam provided on February 24,
2020.
You asked the Plan to waive the copayment for the tissue exam. You say that according to your manual you
have a $0 copayment. You say that you shouldn't be charged. The Plan denied your request. The Plan says the
copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for laboratory tests.
You have been asked to pay a $10 copayment for the tissue exam. The tissue exam 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 for the tissue exam provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided on March 4, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that the enrollee cannot afford the charges. The Plan denied your request. The Plan says 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).
The file shows that the enrollee received a specialist office visit on March 4, 2020. A $45 copay was applied for the services. The visit falls within the physician services benefit category.
An x-ray of the elbow was provided on the date of service at issue. The enrollee was charged $36.26. Because the amount is less than the $45 copay, he was charged the lesser amount. The x-ray falls within the outpatient diagnostic tests benefit category.
A triamcinolone acetonide injection was provided on the date of service at issue. The allowed amount for the injection was $11.60. The enrollee was charged $2.32, which is 20% of the allowed amount. The injection falls within the Medicare Part B benefit category.
The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost shares for the medical services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 3, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 for diagnostic radiology services provided on February 3, 2020.
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 the enrollee can be transferred to the
LTACH for continuation of care of complex medical needs. The Plan denied your request. The Plan says the
denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgery services provided on October 21, 2019.
You asked the Plan to pay for assistant surgery services. You say that the surgeon applied his medical expertise and deemed the assistant surgeon services necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support that an assistant surgeon was necessary for this procedure.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 37224. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 assistant surgery services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent uneventful diagnostic and artery angioplasty/stenting. First assistant services are generally not covered for this procedure. There is nothing in the medical record suggesting that there were any unique features of this procedure that would necessitate over-ruling this determination. There is no documentation of the specific services performed by the assistant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of assistant surgery services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee needs a semi-electric
hospital bed. The Plan denied your request. The Plan says the records do not show that the enrollee needs to
change positions a lot.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
We looked at the file and Medicare rules. The medical record does not support the need for a semi-electric
hospital bed. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital
bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric
hospital bed.
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 the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 required minimal assistance for sit to stand. You required minimal assistance to
walk 80 feet with a rolling walker. The complexity of your nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical
status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit
from multiple therapies such as physical and occupational therapy, but the documentation does not support that
you require an intensive rehabilitation therapy program provided in an IRF.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 81479) provided on December 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 81479 is "Unlisted molecular pathology procedure". We asked our coding 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 use of CPT code 81479 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include an order for an unlisted molecular pathology procedure; therefore, the billed service cannot be verified. We looked at this coder'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 services (CPT 81479) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on September 13, 2019 to December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for injections. You say that you do not want knee surgery. You say that you have had success with these injections. The Plan denied your request. The Plan says no prior authorization was 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 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 injections provided on September 13, 2019 to December 10, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 skilled nursing visits
You asked the Plan to pre-approve the skilled nursing visits. You say that you would like reconsideration because this care is necessary to monitor the complete and sustainable healing of the member's wounds as they transition to regular footwear. The Plan denied your request. The Plan says these services are not medically necessary.
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 the skilled nursing visits. Our reviewer says that the member does not have complex wound care or other skilled nursing needs. Our physician reviewer found the member does not require skilled nursing services to treat their illness or injury, improve or maintain their condition or prevent deterioration. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 skilled nursing visits
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 you are appealing with medical records.
The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals 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 acute
care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of
care for any ongoing long-term care 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 long term acute care hospital (LTACH) services.
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 the care required by the enrollee exceeds
the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee
does not have a current condition requiring daily physician visits, specialized nursing care, or a longer than 25
day stay for acute care.
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 physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for multiple,
chronic, sacral wounds. The enrollee was transiently intubated/ventilated, but is no longer 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.
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.