Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for walker, folding, wheeled, adjustable or
fixed height (E0143) and commode chair, mobile or stationary, with fixed arms (E0163) provided on February
10, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you do not feel you should be liable
for the equipment as you found it inadequate. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received DME on February 10, 2020. You are asked to pay 20% coinsurance
for the DME. Your EOC states, enrollees must pay 20% coinsurance for Medicare-covered DME and related
supplies. 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 walker, folding, wheeled, adjustable or fixed
height (E0143) and commode chair, mobile or stationary, with fixed arms (E0163) provided on February 10,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 10, 2020.You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was your annual wellness visit.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each primary care provider office visit. The medical records show that you received services beyond an annual wellness visit on February 10, 2020. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardioMEMS heart failure monitoring system.
You asked the Plan to pre-approve the cardioMEMS system. You say that the enrollee has class 3 congestive heart failure and has been hospitalized in the last year. You say that the enrollee has a low ejection fraction. The Plan denied your request. The Plan says there has not been enough research done to prove that the requested device will improve the congestive heart failure treatment or reduce problems that would require the enrollee be hospitalized.
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 cardioMEMS system. Our reviewer says that a cardioMEMS system is not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a cardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the cardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that the device should still be considered experimental or investigational. 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 cardioMEMS system have not been met. Therefore, we decided that the Plan does not have to pre-approve cardioMEMS heart failure monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the information does not show any benefit from the prior shot, or how the different shots
help.
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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found in this case, there is no documentation that the enrollee has participated in a physical therapy program,
an activity modification program, or an active rehabilitation/therapeutic exercise program. The requested
sacroiliac joint injections are not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac joint injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on January 23, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says 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 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 lab tests provided on January 23, 2020 by an out
of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs would be best met in
the LTACH as they are able to focus more on vent weaning, which is not possible in the ICU. The Plan denied
your request. The Plan says the criteria for coverage of LTACH care have not been met.
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 was admitted to the acute care hospital for postoperative diaphragm
paralysis requiring mechanical ventilation. He required PEG tube, antibiotics for aspiration pneumonia, and
eventually a tracheostomy due to failure to fully wean. The enrollee has finished IV antibiotics. He still
requires monitoring on nightly ventilation support (BiPAP) only at this time and tracheostomy care as well as
basic wound care and physical therapy. The enrollee appears stable hemodynamically. The enrollee does not
require services at the proposed LTACH that are not already available at the current acute care hospital setting.
here are no services available at the LTACH that the enrollee requires that are not already available and
covered at the current 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).You asked the Plan to pre-approve the ESI. You say that this should be approved.The Plan denied your request. The Plan says this is only covered for radiculopathy which causes pain.The Plan follows Medicare rules. Medicare rules say that ESIs may be covered for enrollees with certain types of back pain caused by spinal nerve root issues. 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 ESI. Our reviewer says that the requested ESI is not considered reasonable and necessary. Our physician reviewer found this 78 year old woman has lumbar radiculopathy with numbness and weakness after lumbar decompression surgery. The progress notes specifically state that there is no pain in the L5 distribution. There is no clinical evidence to support performing an epidural steroid injection in a lumbar radiculopathy which is producing numbness and muscle weakness and not pain. The requested service is not medically reasonable or 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 the ESI have not been met.Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
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 IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF)
care provided January 1, 2020 to January 9, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
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 a $0 copayment each day, for days 1-20 and a $160 copayment each day, for days 21-42, for inpatient
skilled nursing facility care.
The enrollee has been asked to pay a $640 copayment ($160 x 4 days) for inpatient skilled nursing facility care.
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 copayment for the inpatient skilled nursing facility (SNF) care
provided January 1, 2020 to January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe BLS emergency ambulance service (A0429) and ground mileage (A0425) provided December 19, 2019.You asked the Plan to pay forthe ambulance service. You say that the auto insurance has already processed the claim. Please see attached auto insurance EOB and reprocess for payment.The Plan denied your request. The Plan says combined, the automobile insurance payment and the Plan's payment should not exceed the plan's normal allowable amount. Based on the allowed amount for the service, the claim was paid in full by the auto insurance.The Plan must follow Medicare rules. Medicare rules say that The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. ThePlan is not responsible for paying for services until the claim for those services has gone to the primary insurer. The Plan has confirmed that payment made by the enrollee's auto insurance company was more than what would have been paid by Medicare. As the secondary insurer, the Plan cannot be held responsible for this transport as no further reimbursement is available under the Medicare payment guidelines.Therefore, we decided that the Plan does not have to pay forthe BLS emergency ambulance service (A0429) and ground mileage (A0425) provided December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you now understand you need to see an in-network provider. The Plan denied your request. The Plan says 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 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 physician services provided on March 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mirtazapine 7.5mg tablets.
You asked the Plan to pre-approve the mirtazapine tablets. You say that this is necessary to treat the enrollee's
condition. The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B. Part D
coverage must be requested.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve mirtazapine 7.5mg tablets.
Benefits for the mirtazapine tablets may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 11, 2019 to
January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you
believed your phone call to the Plan was considered prior authorization for these services. The Plan denied
your request. The Plan says prior authorization is required for all out-of-network providers and no prior
authorization was found.
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 requires prior
authorization for out-of-network services. 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
January 11, 2019 to January 2, 2020 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 on July 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the ophthalmology services (99203 and 92285). You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are
available in network and the provider did not receive prior authorization.
Medicare rules say that plans may choose the networks of providers available to enrollees and may require
enrollees to obtain authorization before receiving services.
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 1, 2019 by
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 21, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for the pain management services (80307, 81003, 99213 and 82570).
You say that you would like reconsideration because the services rendered were medically necessary. The
Plan denied your request. The Plan says these services are available in-network.
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 February 21,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for anesthesia services. You say that the member had no choice as to who their anesthesia professional would be. The Plan denied your request. The Plan says 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 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 anesthesia services provided on January 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on June 14, 2018.
You asked the Plan to pay for the outpatient hospital services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the outpatient hospital services was not filed until March 27, 2020. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on June
14, 2018.