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

We decided that the Plan does not have to pay for the inpatient hospital care provided from September 23, 2019 to October 3, 2019.
You asked the Plan to pay for the inpatient hospital care. You say that the medical records support the billing of inpatient hospital care from September 23, 2019 to October 3, 2019. The Plan denied your request. The Plan says the inpatient hospital care was not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required. 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 inpatient hospital care. Our reviewer says that the inpatient hospital care was not medically necessary. Our physician reviewer found the review indicates that the enrollee was with a history of dementia and diabetes who was brought to the emergency department on 9/23/19 via ambulance from a custodial facility for a blood sugar reading of 397. The enrollee was worked up in the emergency department with the following results: Vital signs: 97.9 Temp, HR 86, RR 16, 98%, BP 117/62, well developed, well nourished, no acute distress Labs: CBC with Hb 8.0/Hct 26.4, Na 131, BS 285, Creatinine 1.57/ BUN 45. CXR patchy potential infiltrates, diffuse interstitial prominence - possible chronic vs mild pulmonary edema. EKG-no acute changes. The enrollee was admitted for testing pending, acute renal failure. His condition stabilized and improved and he was discharged back to the facility when considered medically stable. The review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation on 9/23/19. There was no documentation provided necessitating post-stabilization care services at the non-Plan facility. Post-stabilization care services at the non-Plan facility were not medically necessary and reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from September 23, 2019 to October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cystourethoscopy surgery provided on November 20, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that you would like this amount reconsidered because this copayment amount is outrageous. The Plan denied your request. The Plan says the copayment amount 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 $400 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay $400 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cystourethoscopy surgery provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on September 26, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the plan requires services to be rendered by contracted providers, with prior authorization requirements.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 rendering 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 office visit services provided to the enrollee on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from October 16, 2019 through October 24, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received. 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). The documentation confirms that you were admitted into the hospital on October 15, 2019 for an acute inpatient detoxification admission. The documentation also confirms that on October 16, 2019, your status was changed to an acute inpatient mental health admission. Therefore, you are asked to pay a $250 copayment for the in-network inpatient mental health care stay. 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 mental health care from October 16, 2019 through October 24, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continuous glucose monitor sensors.You asked the Plan to provide continuous glucose monitor sensors. You say that you need continuous glucose monitor sensors.The Plan denied your request. The Plan says there is no physician order.The Plan must follow Medicare rules. The rules state that DMEPOS are covered only when there is a physician order. The record does not contain a valid physician order.Therefore, we decided that the Plan does not have to provide continuous glucose monitor sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 21, 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 January 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) services provided to the enrollee from September 30, 2019 to October 7, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 HCPCS code S9328 is "home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 infusion therapy (HCPCS S9328) services provided to the enrollee from September 30, 2019 to October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on September 30, 2019.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 mustpay forcare 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 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 forlab services provided to theenrollee on September 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 14, 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 serviced 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 January 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the current wheelchair is able to be repaired.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no evidence that the current wheelchair cannot be repaired. It is also not clear that the enrollee is able to safely navigate the new wheelchair in the home. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee on December 2, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the billed service, 99232, was bundled as part of the global surgical fee because it was reported within 10 days of the minor surgical procedure, removal of tunneled central venous catheter, without subcutaneous port or pump (CPT Code 36589), per CMS Policy.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed service, 99232, was bundled as part of the global surgical fee because it was reported within 10 days of the minor surgical procedure, removal of tunneled central venous catheter, without subcutaneous port or pump (CPT Code 36589), per CMS Policy. According to CMS Policy, the Global Surgical Package includes follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. Therefore, when an Evaluation and Management visit is reported within 10 days of a minor surgical procedure, it will be bundled as part of the global surgical fee. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve chiropractic services. You say that you would like to see this provider because you feel as though she is the only provider who can provide these services.The Plan denied your request. The Plan says there are in-network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. Please contact the Plan about approved in-network providers that are available for these services. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services from November 9, 2019 through November 15, 2019.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. 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 and outpatient diagnostic services from November 9, 2019 through November 15, 2019. Your EOC clearly states, enrollees must pay a $400 copayment per day for days 1 to 4 for Medicare-covered hospital care and enrollees must pay 20% coinsurance for other outpatient diagnostic tests. 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 services from November 9, 2019 through November 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 28, 2019 by an out of network provider. You asked the Plan to pay for the ambulance services. You say that the ambulance services was medically necessary. The Plan denied your request. The Plan says you did not request 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 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 the ambulance services provided on October 28, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to you on October 16, 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 the provider has opted out of Medicare.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that physician has opted out of Medicare. 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 laboratory services rendered to you on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for commode chair, mobile or stationary, with fixed arms (E0163) and walker, folding, wheeled, adjustable or fixed height (E0143) provided on November 4, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received.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 a commode chair, mobile or stationary, with fixed arms (E0163) and walker, folding, wheeled, adjustable or fixed height (E0143) provided on November 4, 2019. You have been asked to pay 20% coinsurance of the allowed amount for durable medical equipment. The allowed amount is $205.64. The total you owe is $41.12 ($205.64 x 20% = $41.12). 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 commode chair, mobile or stationary, with fixed arms (E0163) and walker, folding, wheeled, adjustable or fixed height (E0143) provided on November 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.You asked the Plan to pre-approve the SNF admission. You say that the enrollee cannot walk or stand unaided and needs assistance.The Plan denied your request. The Plan says the enrollee does not meet the criteria and can have the care needed at a lower level of care, such as custodial facility or at home.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve the IRF admission. You say that the program did not listen to you and now should want you to get the best care you can get. You do not think that subacute rehab would be intense enough.The Plan denied your request. The Plan says the interdisciplinary team determined that the enrollee will not able to tolerate level one (acute) rehab which would require over 3 hours per day and is recommending subacute rehab.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 IRF admission. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's inability to tolerate therapies and medical stability. The enrollee's rehab needs should be addressed at a lower intensity such as in an 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 the IRF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vyndaqel 20mg capsule medication. You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Vyndaqel 20mg capsule medication.