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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that currently the enrollee does meet the CMS IRF
admission criteria and her ongoing medical care warrants this level of care to achieve a safe and sustainable
discharge per CMS guidelines. The Plan denied your request. The Plan says based on Medicare's guidelines
and the information the Plan has, the enrollee does not meet the requirements for 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. Our
physician reviewer found the patient does not meet criteria for IRF admission. The enrollee was medically
stable. Functionally, given her inability to participate 3 hours a day of therapies, she does not require IRF level
of therapies. The enrollee may benefit from further PT and OT but does not require an intensive therapy
program. IRF admission is not medically necessary based on the enrollee's current tolerance to activities. The
enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. The enrollee's rehab needs can be met at a lower intensity setting such as in an SNF.
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from January 14, 2020 through February 1, 2020.You asked the Plan to waive the copayment forSNF care. You say that you were not informed of the 60-day prerequisite time between visits into a SNF.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from January 14, 2020 through February 1, 2020. You are asked to pay a $0 copayment per day, days 1-20 at a SNF, a $50 copayment per day, days 21-100 at a SNF, 20% coinsurance per day, days 101-365 at a SNF. Your EOC states, "per benefit period, you pay a $0 copayment per day, days 1-20 at a SNF, a $50 copayment per day, days 21-100 at a SNF, 20% coinsurance per day, days 101-365 at a SNF. A new skilled nursing benefit period will begin on day one when you first enroll in a Medicare Advantage plan, or you have been discharged from a SNF (or not received inpatient skilled level of care) for 60 consecutive days." 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 forSNF care from January 14, 2020 through February 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride treatment provided on March 13, 2020.
You asked the Plan to pay for the fluoride treatment. You say that you didn't see anything in your contract stating a time limitation for fluoride treatments. The Plan denied your request. The Plan says you were not eligible for dental benefits at the time of service.
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 fluoride treatment provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a remote pacemaker evaluation on February 20, 2020.

You asked the Plan to waive the copayment for a remote pacemaker evaluation. You say that you do not know who filed this charge. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $40 copayment for office visits to specialists. 

You have been asked to pay $28.22, which is less than your $40 copayment for a remote pacemaker evaluation. A remote pacemaker evaluation falls within the Physician/Practitioner services, including doctor's office visits 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 a remote pacemaker evaluation on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on March 16,
2020.
You asked the Plan to pay for the lower partial denture (D5214). You say that the denture was broken and
beyond repair. You say that this is a replacement of the old broken partial. The Plan denied your request. The
Plan says the service is not a covered benefit.
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. Therefore, we decided that the Plan does not have to pay for the lower
partial denture (D5214) provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair ramp provided March 22, 2020.You asked the Plan to pay for the wheelchair ramp. You say that the ramp was prescribed by your doctor and you need the ramp to get into and out of your house.The Plan denied your request. The Plan says this is home remodeling or modification item and a convenience item and was purchased from a non-Medicare certified provider.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The plan cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.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 pay for the wheelchair ramp provided March 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laminotomy (63030 and 63035) provided on July 10, 2019.
You asked the Plan to pay for the laminotomy. You say that you would like reconsideration because this
provider was requested to assist in the member's surgery. The Plan denied your request. The Plan says certified
surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services guidelines.
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 a laminotomy (63030 and 63035)
provided on July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism and chair provided on January 20, 2020 by an out of network (OON) provider.You asked the Plan to pay for the seat lift mechanism and chair. You say that these items are medically necessary for you.The Plan denied your request. The Plan says that you were not given approval for out of network services.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 seat lift mechanism and chair provided on January 20, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve knee surgery (29879, 29881). You asked the Plan to pre-approve knee surgery. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 knee surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would support surgical intervention for diagnosis and treatment at this time given the findings of mild osteoarthritis, plausible meniscal symptoms, and failed conservative treatment. Therefore, this request for knee surgery is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have been met.Therefore, we decided that the Plan has to pre-approve knee surgery (29879, 29881). 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: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe definitive drug testing provided on October 10, 2019.You asked the Planto pay forthe drug testing. You say that this was medically necessary testing.The Plandenied your request. The Plansaysthere is no evidence that this provider is actively treating the enrollee for a specific medicalcondition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.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 Plandoes not haveto pay forthe definitive drug testing provided on October 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services that
becomes observation room services from November 1, 2019 to November 4, 2019.
You asked the Plan to waive the emergency room copayment. You say that you do not believe this copayment
is correct. The Plan denied your request. The Plan says based on the medical records, you reported to the
emergency room and were then put into observation. You were not admitted to the hospital as an inpatient and
therefore, the copayment is accurate.
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 $90
copayment for emergency room services. That copayment is only waived if you are admitted to the hospital as
an inpatient status. The records show you were in observation status. 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 $90 copayment
charged for emergency room services that becomes observation room services from November 1, 2019 to
November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray rendered on March 25, 2020.You asked the Plan to waive the copayment forthese services. You say that you already paid the specialist copayment.The Plan denied your request. The Plan says the copayment was 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 $20 copayment for each Medicare-covered standard x-ray service. Review of the file shows that you received a pelvic x-ray on March 25, 2020. These services are separate from the specialist office visit. Per your contract with the Plan, there is a $20 copayment for each Medicare-covered standard x-ray service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $19.50. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $19.50 for these services. Therefore, we decided that the Plan does not have to waive the copayment forthe x-ray rendered on March 25, 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 services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergy injection provided on March 26,
2020.
You asked the Plan to waive the copayment for the allergy injection. You say that you have not been charged a
copayment for allergy shots prior to 2020. 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 $20
copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of
the claim because this amount is less than the $20 copayment for the allergy injection.
You have been asked to pay an $8.98 copayment for the allergy injection. The allergy injection falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the
allergy injection is considered a physician service.
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 allergy injection provided on March 26, 2020.
Our decision is only about the March 26, 2020 service. If you have any questions about prior years billing,
please contact the plan directly.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from
December 15, 2019 to December 23, 2019.
You asked the Plan to pay for the services. You say that this should be reconsidered, as it is a per visit claim.
The Plan denied your request. The Plan says the claim cannot be reprocessed for payment until a corrected
claim is received.
The Plan must follow Medicare rules. Medicare rules say that home health services must be reported correctly,
including a valid FIPS code.
A review of the file shows that the FIPS code is missing from the claim. 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 home health services provided to the enrollee from December 15, 2019 to December 23,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora visual field examination provided on October 26, 2019 by a non-contracted provider.  You asked the Plan to pay forthe service. You say that you do not understand why your vision coverage was denied.The Plan denied your request. The Plan says you signed a form regarding the Visual Field Screening, consenting to a $15.00 fee for the screening exam and that your plan does not guarantee reimbursement.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. This service is not listed in your EOC as a covered benefit. Your EOC states, "a routine eye exam is covered under your medical benefits onceper calendar year. Post cataract surgery and associated eyewear is covered under yourmedical benefits. You have a $200 reimbursement allowance toward the purchase of eyewear. The benefit applies to corrective (prescription) glasses, lenses, frames and/or contact lenses purchased from a participating or nonparticipating provider. After the plan-paid benefits, the member is responsible for the remaining cost.".Therefore, we decided that the Plan does not have to pay fora visual field examination provided on October 26, 2019 by a non-contracted provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 4, 2020 through February 5, 2020. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. Inpatient admission was not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 4, 2020 through February 5, 2020.