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

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 24, 2020, to July 26, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that inpatient admission was 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 the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the enrollee had a fever of 103 degrees with rigors two days after instrumentation of the biliary system during the COVID-19 pandemic. A reasonable physician would expect this admission to span two midnights, as was done in this case. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 24, 2020, to July 26, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts.
You asked the Plan to pre-approve these services. You say that you have a heel spur and plantar fasciitis. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the ambulance transport provided on November 13, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were in the hospital at that time. You say that this run was not for you. The Plan denied your request. The Plan says that the copayment applied correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The ambulance transport was billed for November 13, 2020, but the documentation submitted does not support you were transported by ambulance on that date. Therefore, we decided that the Plan has to waive the copayment for the ambulance transport provided on November 13, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connector (E2311) for a power wheelchair.
You asked the Plan to pre-approve the electronic connector. You say that the electronic connector is medically necessary. The Plan denied your request. The Plan says the records do not support that the enrollee requires the ability to control the power features through the joystick. The requested electronic features exceed the enrollee's needs.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the electronic connector. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found documentation does not reveal that the patient requires other types of proportional input devices or non-proportional input devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The patient's strength and function in the upper extremities indicates that the patient can control any power options through their own individual switches. 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 electronic connector have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connector (E2311) for a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health visits (G0299).
You asked the Plan to pre-approve the additional home health visits. You say that the home health visits are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 additional home health visits. Our reviewer says that the additional home health services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs 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 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits (G0299).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 4, 2020. You asked the Plan to pay for the testing services. You say that the testing provides risk analytics to assist with disease detection. The Plan denied your request. The Plan says the services do not meet coverage requirements. The Plan must follow Medicare rules. Medicare rules say the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We find that the testing services are not supported. Coverage for all non-lipid biomarkers when used for CV risk assessment, including genetic biomarkers, are not covered. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation provided on November 25, 2020.
You asked the Plan to pay for ambulance transport. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because transportation by means other than ambulance may have been an option.
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 ambulance transport. Our reviewer says that this transport does not meet the Medicare criteria for coverage. Our physician reviewer found the documentation provided does not show any contraindication for the enrollee to use other means of transport (such as stretcher van). There was no documented need for the expertise, services, and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. This transportation is not considered medically necessary based on the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation provided on November 25, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that the stay 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 in the Medicare rules section 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 SNF care. Our physician reviewer found based on the documentation provided, the enrollee does qualify for SNF coverage. The enrollee does have documented skilled nursing needs, requiring daily intravenous (IV) antibiotics through at least April 20, 2021. The enrollee does not have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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 SNF care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) with suspension sleeve (L2397) provided on August 31, 2020.
You asked the Plan to pay for a knee orthosis with suspension sleeve. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for payment have not been met because it appears the enrollee did not receive a video or telephonic visit by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis with suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record does not support that there has been recent injury or surgery. The elements of the Medicare guidelines for the knee orthosis are not satisfied. Therefore, the knee orthosis cannot be recommended. The elements of the Medicare guidelines for the suspension sleeve are not satisfied because the knee orthosis is denied as not medically reasonable and necessary. Therefore, the suspension sleeve cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Furthermore, the requested suspension
sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) with suspension sleeve (L2397) provided on August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs, the laboratory work and the CT scans provided on August 20, 2020.
You asked the Plan to waive the coinsurance for the Part B drugs, the laboratory work and the CT scans. You say that you believe the services should be included as a part of your surgery and you do not agree with the costs. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for Medicare Part B prescription drugs, 10% coinsurance for laboratory tests, and 20% coinsurance for diagnostic radiology. You have been asked to pay at total of $417.04 for the Part B drugs, the laboratory work and the CT scans. The Part B drugs fall into the "Medicare Part B prescription drugs" benefit category. The laboratory work and the CT scans fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which states the coinsurance would be waived as a part of a surgical procedure. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
August 20, 2020
Part B drugs
$34.71
20%
$6.94
August 20, 2020
Laboratory work
$223.57
10%
$22.37
August 20, 2020
CT scan - thorax
$451.48
20%
$90.30
August 20, 2020
CT scan - abdomen/pelvis
$1,487.15
20%
$297.43
Total
$417.04
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 the Part B drugs, the laboratory work, and the CT scans provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a hip arthoplasty surgery.
You asked the Plan to pre-approve an acute inpatient hospital admission. You say that an inpatient hospital admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient hospital admission.
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 pre-approve acute inpatient hospital care. Our reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer found that the review indicates that the surgery current procedural terminology (CPT) code given is no longer on the Medicare Inpatient Only List. The documentation preoperatively shows that the enrollee has a history of underlying hypertension, rheumatoid arthritis, a prior cerebrovascular accident (CVA), dyslipidemia, and a prior deep vein thrombosis (DVT). The records provided with the request show that the hypertension and dyslipidemia are stable on medication and the CVA and DVT are both historical. The enrollee is medically stable. The record does not show that the admitting physician would reasonably expect that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an acute inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a hip arthoplasty surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services you received from July 16, 2020, to August 12, 2020.
You asked the Plan to waive the copayments for the PT services. You say that you did not know that these services had a copayment. The Plan denied your request. The Plan says these copayments were charged 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 $30 copayment for physical therapy services. Records show that between July 16, 2020, and August 12, 2020, you had seven PT visits. You have been asked to pay a $30 copayment for each of the PT services. 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 copayments for the physical therapy (PT) services you received from July 16, 2020, to August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery provided from September 21, 2020, through September 22, 2020.
You asked the Plan to pay for the surgery. The Plan denied your request. The Plan says the enrollee must seek care from an in-network provided unless the services are urgent/emergent. The enrollee is responsible for paying the full cost of services that are not covered by our Plan, either because they are not Plan covered services or they were obtained out-of-network and 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 did not pre-approve the surgery. 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 surgery provided from September 21, 2020, through September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on September 30, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the member is being treated by the ordering physician. Of note, the member and laboratory are located in Texas while the ordering physician is located in Illinois. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on September 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital on October 30, 2020. You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you were told that you were incorrectly charged. The Plan denied your request. The Plan says the correct copayment 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 $360 copayment for outpatient hospital coverage/in-network/outpatient hospital. You have been asked to pay a $360 copayment for diagnostic colonoscopy. Diagnostic colonoscopy falls within the outpatient hospital coverage/in-network/outpatient hospital 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 an outpatient surgery provided by a participating provider on October 30, 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 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 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 enrollee had pneumonia and breathing problems requiring a ventilator machine and is now breathing on her own through a tracheostomy tube. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the enrollee does not meet criteria for the requested 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 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.