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

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there does not appear to be any advantage for the enrollee to be transferred to the long term acute care hospital.

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 appears to be unstable and requires additional acute care services. Care can be administered safely at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.

Therefore, LTACH services will be considered not medically necessary as they would provide no advantage to continuing short-term additional care at the current facility at this time, and it would be unsafe. Transfer may be considered at a later time when treatment has completed and the enrollee is more stable. 

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 21, 2020, to February 6, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you have overpaid the maximum out of pocket for in-network services. The Plan denied your request. The Plan says the copayment 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 a $298 copayment per day, for days 1-7 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $0 copayment per day, for days 8-90 for inpatient hospital care.
You have been asked to pay a $298 copayment per day for inpatient hospital care. The records show you were in inpatient hospital care for sixteen days. The cost share was applied for the first 7 days ($298 x 7days = $2,086). The EOC confirms that $298 per day is the required copayment for this service. The records also show that at the time this claim was processed you had met $2,206 of your total in-network out of pocket expense. Please note, you switched plans as of February 1, 2020. 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 on January 21, 2020, to February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2020.
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 lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory testing provided to the enrollee on April 19, 2021.

You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your request. The Plan says multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered.

The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

The complexity of the testing at issue in this case is not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve laboratory testing provided to the enrollee on April 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the pacemaker evaluation received on April 28, 2021.

You asked the Plan to pay for the pacemaker evaluation. You say that you advise that this service was requested and approved by the provider. The Plan denied your request. The Plan says that the services need to be charged to your medical group for payment.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were provided the pacemaker evaluation by a contract provider. The file does not show that the Plan provided notice that the pacemaker evaluation would not be covered. Under Medicare rules, this means the pacemaker evaluation is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the pacemaker evaluation received on April 28, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170).

You asked the Plan to pre-approve additional mileage. You say that you need transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 60 one-way trips with each one-way trip not exceeding 50 miles of driving distance.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 101 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation of nerves innervating the 
sacroiliac joint (64625) provided April 12, 2021. 
 
You asked the Plan to pay for the radiofrequency ablation of nerves innervating the sacroiliac joint. You say 
that this procedure was medically necessary. The Plan denied your request. The Plan says this service is 
considered not medically necessary/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. 
 
We looked at the file and Medicare rules. In this case, the requested radiofrequency ablation used for sacroiliac 
joint pain is not medically necessary as Medicare rules specifically excludes it from coverage. 

Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation of 
nerves innervating the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to 
pay for the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) provided April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an observation physician visit provided on June 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician visit. You say that your physician is hospital-based and relies on the facility to obtain proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an observation physician visit provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care, from October 4, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that you have open wounds and are diabetic. You state you are weak and have dementia. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care, from October 4, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on January 11, 2021.

You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acupuncture, one or more needles, without
electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical
stimulation, each additional 15 minutes (97811) provided February 10, 2021 to March 17, 2021.

You asked the Plan to waive the copayment for the acupuncture services. You say that your plan costs
hundreds per month and page 67 of the manual indicates 12 visits in 90 days. You request immediate action
and approval for your claim. The Plan denied your request. The Plan says the claims were processed with 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 $35
copayment for each specialist's office visit.

You have been asked to pay $210 ($35 x 6 visits) for the acupuncture services. The acupuncture services fall
within the Acupuncture (Medicare covered) for chronic low back pain 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 acupuncture, one or more needles, without electrical stimulation,
initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15
minutes (97811) provided February 10, 2021 to March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on December 28, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing rendered on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 4, 2020. 
 
You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your 
request. The Plan says this was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing (G0483) provided on November 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The Plan denied your request. The Plan says the requested Synvisc is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Synvisc. Our reviewer says that the requested Synvisc is not medically necessary. Our physician reviewer found the enrollee is with chronic left shoulder pain due to osteoarthritis/glenohumeral and acromioclavicular joint arthritic changes. The enrollee has tried massage and rest, physical therapy, and Tramadol. There is not enough support for Synvisc for use in the treatment of osteoarthritis of the shoulder. This use of viscosupplementation is not supported by the FDA and/or nationally recognized compendia. The review has determined that the documentation does not support that the Synvisc is medically reasonable or necessary for the enrollee. The documentation does not support that the Synvisc is safe and effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital care provided April 9, 2021 to April 11, 2021.
You asked the Plan to pre-approve the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, in this case the plan did not provide a copy of the denial rationale to the IRE for review. Additional information was requested and clinical documentation was received, however no denial rationale was provided. Therefore, we decided that the Plan has to pre-approve inpatient hospital care provided April 9, 2021 to April 11, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on September 10, 2020 by an out-of-network (OON) provider.

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 services were rendered by an out-of-network provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the Ketamine infusion provided on September 10, 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 laboratory services provided on March 30, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The laboratory services at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 30, 2021.