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

We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from November 29, 2019, through December 13, 2019.

You asked the Plan to pay for the IRF care. You say that the acute inpatient rehabilitation facility admission was medically necessary. The Plan denied your request. The Plan says that the IRF admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that an 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 pay for IRF care. Our reviewer says that the IRF care provided is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical conditions were stable. There were no medical needs requiring an inpatient admission. There were no complex nursing or rehabilitation needs. 

The patient did not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documented a need for physical and occupational therapy, it did not document a need for an intensive rehabilitation program. 

There was not a reasonable expectation that this patient would be able to fully participate in and benefit from 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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from November 29, 2019, through December 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you no longer need inpatient rehabilitation facility care and should be transferred to a SNF. The Plan denied your request. The Plan says you need to remain in the inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the criteria for coverage of SNF care have not been met. Our physician reviewer found the record shows that you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You continue to require skilled services on a daily basis. Although you are making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medical eye examination (92014) provided October 12, 2020.

You asked the Plan to waive the copayment for the vision services. You say that this was scheduled as a routine eye exam and should be covered at 100%. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $35 copayment for Medicare covered eye exam to diagnose and treat diseases and conditions of the eye. 

You have been asked to pay $35 copayment for Medicare covered eye exam to diagnose and treat diseases and conditions of the eye. The plan confirmed that the appointment was for a routine eye exam but turned into a medical eye exam due to history of cataracts, ocular hypertension, and posterior capsule opacification. The vision services fall within the Vision care 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 medical eye examination (92014) provided October 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was supposed to have a $0 copayment. You say that this was not diagnostic. 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 $250 copayment for outpatient surgery/surgery.

You have been asked to pay a $250 copayment for a diagnostic colonoscopy. The colonoscopy was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/surgery 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 diagnostic colonoscopy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 ophthalmological services. 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 ophthalmological services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair (K0861) with expandable controller upgrade (E2377), electric connect between wheelchair controller (E2311), sealed lead acid battery (E2361), access harness upgrade (E2313), manual swing away joystick (E1028), power seat tilt and recline (E1007), power center footplate (E1012), padded headrest (E0955) and ridge cushion (E2606).

You asked the Plan to pre-approve power wheelchair (K0861) with accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not 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 a power wheelchair (K0861) with accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the patient does not meet group 3 power wheelchair coverage criteria as there is no documentation of neurologic disorder, myopathy or congenital skeletal diagnosis therefore the requested code K0861 Group 3 is not medically necessary.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
If the group 3 power wheelchair is not medically necessary, than all accessories will also be found as 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 a power wheelchair and accessories have not been met. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve power wheelchair (K0861) with expandable controller upgrade (E2377), electric connect between wheelchair controller (E2311), sealed lead acid battery (E2361), access harness upgrade (E2313), manual swing away joystick (E1028), power seat tilt and recline (E1007), power center footplate (E1012), padded headrest (E0955) and ridge cushion (E2606).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair and knee scooter.

You asked the Plan to pay for the provided items. You say that you cannot use crutches, and cannot bear weight. The Plan denied your request. The Plan says the items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. A knee scooter will be denied not medically necessary.

While a shower chair and knee scooter may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for a shower chair and knee scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services (D2950, D2740, D5110, D7250, D5214) to be provided by an out of network provider.

You asked the Plan to pre-approve the dental services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider with the exception being urgent or emergent services.

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 covered when rendered by an out of network provider. You can find this information on page 55 of the EOC. 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. Therefore, we decided that the Plan does not have to pre-approve the dental services (D2950, D2740, D5110, D7250, D5214) to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home infusion services (S9502).

You asked the Plan to waive the coinsurance for the home infusion services. You say that the enrollee should not be charged a coinsurance because the provider provided unsatisfactory service. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% of the plan-allowed amount for Medicare Part B prescription drugs.

The enrollee has been asked to pay a total of $80.64 ($403.13 allowed amount x 20% coinsurance) for the home infusion services. These services fall within the Medicare Part B prescription drugs benefit category. This means that 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 coinsurance for home infusion services (S9502).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve standard supply allowance (K0553-12 units) for a continuous glucose monitor.

You asked the Plan to pre-approve standard supply allowance (K0553-12 units) for a continuous glucose monitor. You say that the service is medically necessary. 

The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 standard supply allowance (K0553-12 units) for a continuous glucose monitor. Our reviewer says that the service is not medically necessary. Our physician reviewer found the beneficiary has been using a blood glucose monitor (BGM) and is not performing frequent (four or more times a day) testing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of standard supply allowance (K0553-12 units) for a continuous glucose monitor have not been met. Specifically, documentation shows that the member does not meet the criteria for a CGM. This means that the allowance for a CGM is not medically necessary or reasonable for this member. Therefore, we decided that the Plan does not have to pre-approve standard supply allowance (K0553-12 units) for a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two of the three days of your inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient care. You say that you want the copayments for your second and third day of your hospital stay waived because you should have been discharged after one night. You state that there was no home care agency available right away and the hospital delayed your discharge for this reason. The Plan denied your request. The Plan says medical records were provided to show that inpatient services were rendered on two of the three days of care. Each of the first five days of an inpatient hospital stay is subject to a $350 copayment.

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 $350 copayment for each of the first five days of an inpatient hospital stay.

You have been asked to pay a $1,050 copayment for three days of inpatient care ($350 x 3 = $1,050). The provided medical records show that services were rendered on the days at issue. 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 two of the three days of your inpatient hospital stay.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for two Computed Tomography (CT) scans (71250, 74176).

You asked the Plan to waive the copayments for the CT scans. You say that only one copayment should be applied. The Plan denied your request. The Plan says two scans were performed, so the correct copayments were 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 $110 copayment for each Diagnostic Radiology procedure.

You have been asked to pay a $110 copayment for each CT scan, for a total of $220.00. The CT scans fall within the Diagnostic Radiology 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 copayments for two Computed Tomography (CT) scans (71250, 74176).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued.

You asked the Plan to pay for the compression stockings. You say that the requested item is imperative for health reasons. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 80307 & G0483 is not supported in the medical record. Specifically, the place of service listed on the claim form (POS 11) does not match the place of service documented in the medical records (POS 57). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960).

You asked the Plan to pay for the orthosis. You say that please find the attached documents and reprocess the claim towards payment. The Plan denied your request. The Plan says evidence of misrepresented services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted and is not itemized. The delivery ticket submitted did not include the carriers tracking number. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960).