Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that your functional and cognitive deficient and gait instability and would benefit from ongoing physical therapy for the next one to two weeks at a SNF. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your records do not show that you require daily skilled services that can only be provided on an inpatient basis. The Plan states the services you require, such as additional therapy services, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (G0463, 85025, 80048, 80076) provided on June 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that the provider has requested network participation. The Plan denied your request. The Plan says this was not authorized.  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 laboratory services (G0463, 85025, 80048, 80076) provided on June 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the wearable external defibrillator (LifeVest) you rented from May 2, 2021, to July 2, 2021.  You asked the Plan to waive the coinsurance for the LifeVest. You say that no one told you that this would be a recurring monthly payment.  You stated that you returned the LifeVest on July 20, 2021, as it was too heavy and hurting your back. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment benefit category. The LifeVest is a capped rental item, meaning that it can only be rented.  So, monthly rental payments are required. 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 the wearable external defibrillator (LifeVest) you rented from May 2, 2021, to July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 22, 2021.  You asked the Plan to pay for the transportation service. You say that this should be covered. You say that you fell and were not able to get up. You say that the emergency medical technician (EMT) advised you did not need to go to the hospital after taking your vitals. You also say that you will be going to the emergency room as you do not agree with what the EMT said. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since there was no transport provided, there is no payable service.  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 July 22, 2021. 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 response and treatment, no transport, (A0998) provided on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80307, 82542, 84228, G0483) provided on July 15, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and there were 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 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 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 for lab services (80307, 82542, 84228, G0483) provided on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.  You asked the Plan to pre-approve the Prolia injections. You say that it is felt this is medically necessary to increase the enrollee's bone density. The Plan denied your request. The Plan says this drug is not medically necessary at this time.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia injections. Our reviewer says that the requested use of Prolia is not considered reasonable and necessary. Our physician reviewer found Prolia is supported for improving bone mineral density in postmenopausal patients with osteoporosis.  In this case, the record indicates that the enrollee has a diagnosis of age-related osteopenia, not osteoporosis, demonstrated by bone density scanning. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.   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 Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on June 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that you are a participating provider and do not need pre-authorization. The Plan denied your request. The Plan says no prior authorization was 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 the drug testing provided on June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 28, 2020.  You asked the Plan to pay for the ambulance service. You say that you called the number on your card and were advised to call an ambulance. You say that you did not want an ambulance. You say that the nurse called the ambulance dispatch, and an ambulance was sent. You also say that you should not be responsible for this bill because you did not want an ambulance to be sent in the first place. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since there was no transport provider, there is no coverable service.  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 28, 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 response and treatment, no transport, (A0998) provided on June 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care from December 3, 2021, forward.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that 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 is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care from December 3, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on August 5, 2020.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on August 5, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 9, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you were discharged from the hospital earlier that day and had to return to the ER because your heart rate shot up.  You say that the Plan should cover half of the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on July 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on June 16, 2021.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the ambulance services rendered were medically necessary. The Plan denied your request. The Plan says the record indicates that the member was registered inpatient on the billed date of service.  The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that the member was registered inpatient from June 14, 2021, through June 17, 2021. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission and not separately payable. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on June 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nine (9) home health physical therapy visits (Current Procedural Terminology (CPT) code G0151 X 9), for the enrollee.  You asked the Plan to pre-approve the services. You say that home health physical therapist visits are medically necessary. The Plan denied your request. The Plan says they previously approved visits to teach the enrollee and their caregiver(s) a home exercise program. The Plan states the enrollee's records suggest that continuing this exercise program should help you maintain the enrollee's level of function or improve further. The Plan states they do not show that additional home physical therapy visits are needed for this to occur. The Plan states the enrollee's records do not support the need for a skilled physical therapist to make more home visits at this time.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 services. Our physician reviewer found the documentation does not support that skilled therapy services continue to be required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) home health physical therapy visits (Current Procedural Terminology (CPT) code G0151 X 9), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 8, 2021, to August 14, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not aware that you would have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital care.   Records show that you were in the hospital for 6 days.  According to your contract, you are responsible for a $350 copayment per day for days 1-5, which would total $1750. However, the Plan is currently only charging you $1400.  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 services you received from August 8, 2021, to August 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee is a fall risk and currently lives alone and requires twenty-four (24) hours supervision. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your records does not show that the enrollee requires daily skilled services that can only be provided on an inpatient basis. The Plan states the services the enrollee requires, such as additional therapy services, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.  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 based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.