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

We decided that the Plan has to pay forthe acute inpatient hospital care provided from February 29, 2020, through March 8, 2020.You asked the Plan to pay forthe acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary for the enrollee.The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room on February 29, 2020 with complaints ofa cough and increased bilateral leg swelling. Evaluation revealededema of the lower extremities; the chest x-ray revealed a right pleural effusion, the B-type natriuretic peptide (BNP) was elevated to 6,039 and the urinalysis was suggestive of infection. She was treated with IV Lasix and IV Ceftriaxone and was admitted. Her condition stabilized and improved with medical therapy and she was discharged when considered medically stable on March 8, 2020. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay fortheacute inpatient hospital care provided from February 29, 2020, through March 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210) provided on January 7, 2020.
You asked the Plan to reimburse you for the dental service. You say that you were assured that your dentist and the dental office had a great working relationship with your plan. You say that you were assured that you would receive a check. You say that you are on a fixed income. You also say that you were counting on this reimbursement. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the surgical extraction (D7210) provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services provided on May 14, 2020.
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a psychiatric diagnostic evaluation with medical services provided on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on March 20, 2020.
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 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 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 out of network lab services provided to the enrollee on March 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 31, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not in hospice at the time of service. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before the end of that month
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on July 31, 2020.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 does require physical therapy and occupational therapy services
but the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the
enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility due to decreased endurance. Care at the skilled nursing facility
level appears to be more appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 pay for a domiciliary, rest home visit provided on July 6, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on July 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2020 by an out of
network provider.
You asked the Plan to pay for the cystourethroscopy (52000). You say that the services were 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 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 24, 2020 by
an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the neck.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there must be notes about other tests that have been done for this problem.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the physician's notes do not provide justification of the requested CT of the neck. In some parts of the brief records, there is an impression of sinus disease, for which a CT of the paranasal sinuses may be in order. If there indeed is a soft tissue lump at the base of the tongue as claimed, a CT of the neck could be in order. The records provided in this case simply do not explain the specific scan desired, nor is there a discussion concerning what plan there is based upon scan results. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the neck.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent outpatient office visits for the
evaluation and management of an established patient (99213, 99214) provided June 22, 2020 to July 10, 2020
You asked the Plan to waive the copayment for the office visits. You say that you have ever had a copay in the
past. You're on a limited income and cannot afford to pay. You feel that you should not have to pay the
copayments for the office visits. The Plan denied your request. The Plan says this claim has been processed and
the correct copayment applied per the plan 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). Your contract with the Plan clearly says that you must pay $20
copayment for Urgently needed services.
You have been asked to pay $40 copayment for the office visits. The office visits fall within the Urgently
needed services 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 urgent outpatient office
visits for the evaluation and management of an established patient (99213, 99214) provided June 22, 2020 to
July 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 28, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physical therapy 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 physical therapy services provided on January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating
provider on July 23, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you paid a $30 copayment and that
should cover this. 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 $225
copayment for outpatient diagnostic tests/diagnostic radiology services.
You have been asked to pay $212.47 which is less than your copayment amount of $225 for a CT scan. A CT
scan falls within the outpatient diagnostic tests/diagnostic radiology services 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 CT scan provided by a participating provider on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided
March 5, 2020.
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that you think this is
an unreasonable amount of money. You've had this plan for many years and it's always been covered with a
small copay for several hospital visits. The Plan denied your request. The Plan says this claim was processed
and the correct copayment 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 $400
copayment for outpatient hospital facility.
You have been asked to pay $400 copayment for the outpatient surgical procedure. The outpatient surgical
procedure 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 the
outpatient surgical procedure provided March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the retainer crown (D6740) provided on May 21, 2020.
You asked the Plan to reimburse you for the dental service. You say that your Annual Notice of Changes (ANOC) for 2020 makes no reference to a Medicare dentist. You say that in the past your plan was a reimbursement plan and a Medicare dentist was not required. You say that if you had been alerted to this problem, you would have changed dentists. You also say that you were counting on the reimbursement as this was a lot of money for you. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services that you receive from an provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the retainer crown (D6740) provided on May 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidural injections.
You asked the Plan to pre-approve Epidural injections. You say that the requested epidural injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Epidural injection.
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 Epidural injections. Our reviewer says that the enrollee does not meet criteria for the requested Epidural injection. Our physician reviewer found a cervical steroid injection is requested to treat M50.20 - Other cervical disc displacement, unspecified. The prescriber states that the planned procedure is a midline injection at C5-C6 for treatment of neck pain radiating to the arms/shoulders bilaterally. The prescriber has indicated that a previous cervical epidural injection performed October 7, 2020 was beneficial; to reduce pain and increase functioning; however, symptoms have recurred. The prescriber states that the enrollee does not have any of the 6 conditions stated in the plan's denial letter for which the requested procedure is contraindicated. The clinical information stated in the prescriber's letter of reconsideration and the applicable LCD - Epidural Injections for Pain Management (L36920) were reviewed. The enrollee is noted to have an appropriate indication for the requested procedure; however, there is no documentation that the proposed procedure will be done under image-guidance. As such, the documentation required per the noted LCD have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Epidural injections.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 do require physical therapy and occupational therapy services but you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to weakness, dyspnea and poor endurance. Care at the skilled nursing facility level appears to be more appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 8, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 8, 2020.