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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from February 27, 2019 through March 5, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that the hospital was ready to discharge you on February 28, 2019, but instead kept you an additional three days. You state you called the Plan and were told someone from the hospital advised that they needed you to stay the additional days.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 inpatient hospital care provided from February 27, 2019 through March 5, 2019. You are asked to pay a $300 copayment per day for days 1-6. 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 inpatient hospital care provided from February 27, 2019 through March 5, 2019
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 disagree with the denial.The Plan denied your request. The Plan says the services are 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-approvethe LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you are currently at an acute care hospital (ACH) and were admitted with lumbar discitis. You were found to have endocarditis and underwent heart surgery. The post-operative course was complicated by respiratory failure and required a breathing tube. You are not appropriate for ventilator weaning and may remain at the ACH until no acute services are needed.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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis, urine culture/colony count, and susceptibility studies, antimicrobial agent provided on May 22, 2019.
You asked the Plan to pay for the urinalysis, urine culture/colony count, and susceptibility studies, antimicrobial agent. You say that the services were not related to the hospice terminal diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the urinalysis, urine culture/colony count, and susceptibility studies, antimicrobial agent provided on May 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has neck pain and the records indicate he has been having neck and shoulder pain. The treatment plan is to start Medrol dose pack and request MRI. Cervical MRI is indicated if unequivocal findings identify specific nerve compromise on the neurologic examination in patients who do not respond to conservative treatment and who would consider surgical intervention. In this case there are no documented neurologic abnormalities on exam; therefore, the MRI is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ED visit, diagnostic imaging procedures, laboratory services, cardiography procedures, and drug administration services provided on September 3, 2019.You asked the Plan to pay for the ED visit and services. You say that the enrollee was discharged to hospice from the emergency room.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the ED visit, diagnostic imaging procedures, laboratory services, cardiography procedures, and drug administration services provided on September 3, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 1, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 physician's services provided on August 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on August 20, 2019.You asked the Plan to pay for Paramedic intercept services. You say that you feel that since the doctor ordered the ambulance the ALS emergency treatment should be covered.The Plan denied your request. The Plan says this service is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay for paramedic intercept services (A0432) provided by on August20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed (E0303). You asked the Plan to pre-approve the hospital bed. You say that you feel that this request is medically necessary and should be covered.The Plan denied your request. The Plan says the records shows you weigh 250 pounds therefore you do not meet the medical necessity criteria for a heavy duty extra wide hospital bed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The guideline states a heavy duty extra wide hospital bed is intended for use for a person who weighs 300 to 600 pounds. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on June 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99053 is not supported.
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 99053 is service(s) provided between 10:00 PM and 8:00
AM at 24-hour facility, in addition to basic service.
We find that CPT code 99053 is not supported in the medical record. Specifically, this code is an add-on code
that was not billed with a required primary procedure code. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the services rendered on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 22, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 physician's services provided on August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis rendered to you on July 22, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77062 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider submitted a claim for procedure code 77062 (digital breast tomosynthesis). This code has a status indicator of I and is not valid for Medicare purposes. The Plan states that you will not be responsible for these charges. Therefore, we decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis rendered to you on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 26, 2019 by out of network provider. You asked the Plan to pay for diagnostic testing. You say that the Provider is requesting payment for the services provided.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 medical services provided on July 26, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physician services rendered to you on August 22, 2019 to September 24, 2019.
You asked the Plan to waive the copayments for these services. You say that you are displeased with the services. The Plan denied your request. The Plan says the copayments were 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 $5 copayment per visit for primary care physician (PCP) visits.
Review of the file shows that you had a visit with your PCP on August 22, 2019 and September 24, 2019. You have been asked to pay a $5 copayment per visit for these services, for a total of $10. These services fall within the primary care physician (PCP) 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 copayments for the physician services rendered to you on August 22, 2019 to September 24, 2019.
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J2345).
You asked the Plan to pre-approve Ilumya. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Ilumya. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Remicade or Inflectra, and Stelara would likely be less effective, and/or would likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J2345).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 3, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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 physician's services provided on September 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after January 17, 2020.You asked the Plan to pre-approvecontinued SNF care. You say that you do not feel you are ready to go home.The Plan denied your request. The Plan says the denial of authorization for continued SNF care after January 17, 2020 is correct.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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 26, 2019
through July 28, 2019.
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 medical records provided indicate that the admitting physician expected the
enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no
advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time
of admission. Inpatient care services were not supported by the documentation.
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 July 26, 2019 through July 28,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat with rail.
You asked the Plan to pre-approve a raised toilet seat with rail. You say that you feel that you need this because you fell about a month ago and it hurts your knee when you try to sit on the toilet. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat with rail.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture (D5110) and complete lower denture (D5120). You asked the Plan to pre-approve the upper and lower dentures. You say that you lost your dentures and need another pair.The Plan denied your request. The Plan says this request exceeds the benefit limit.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. This service is covered once every 5 years. Records show you received this service on November 3 2015. This service will not be eligible for coverage until November 3, 2020.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 pre-approve complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 2,
2019 to October 21, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no
valid proof of delivery.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from August 2, 2019 to October 21, 2019.