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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are 103 years old, wheelchair-bound, and require care in a SNF. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing services or daily skilled therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from June 5, 2020 to July 14, 2020.
You asked the Plan to waive the copayment for these services. You say that the charges should be paid by the Plan. The Plan denied your request. The Plan says the copayment was applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment per day for days 1-5 for in-network inpatient hospital care.
Review of the file shows that the enrollee received inpatient hospital services from June 5, 2020 to July 14, 2020. The enrollee has been asked to pay a $325 copayment per day for days 1-5 for these services, for a total of $1,625. These services fall within the in-network inpatient hospital care benefit category. 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 hospital services rendered from June 5, 2020 to July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on December 22, 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 services were not billed correctly.  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 laboratory services rendered on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 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 documentation provided, the health plan's denial should be upheld. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care
needs can be met at a lower level of care.
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for lab services you received on July 7, 2021.  You asked the Plan to waive the deductible for the lab services. You say that you have never had to pay anything for lab services in the past. The Plan denied your request. The Plan says you had not satisfied your deductible at the time of these lab services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to lab services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on July 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services you received on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on February 13, 2021.  You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for the provided CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on February 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the IRF services. The Plan denied
your request. The Plan says this request is not medically necessary.
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 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. Our reviewer
found that the enrollee's medical status does not require intensive physician or nursing supervision in an IRF.
Our physician reviewer also found that while the enrollee may benefit and participate in multiple therapies, the
enrollee's functional level does not require this on an intensive rehabilitation therapy program provided in an
IRF.
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (G0482) rendered by the out-of-network (OON) provider on June 25, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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  provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0482) rendered by the out-of-network (OON) provider on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for self-administered drugs provided from July 16, 2021, to July 17, 2021.  You asked the Plan to pay for self-administered drugs. You say that your emergency care copayment is only $90 so the billing should not be over this amount. The Plan denied your request. The Plan says these drugs are not covered.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for self-administered drugs provided from July 16, 2021, to July 17, 2021.   Benefits for self-administered drugs 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on December 11, 2020.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve drug regimen Alimta, Carboplatin, Pembrolizumab, Fosaprepitant, and Palonosetron.
You asked the Plan to pre-approve the requested regimen. The Plan denied your request. The Plan says that the documentation does not support the use of this regimen for first line therapy for the enrollee's disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested regimen. Our physician reviewer found that the requested drug regimen is the standard of care. His MET amplification and CDK4 have targeted therapies for other types of cancer, but not for this enrollee's diagnosis of lung cancer. The documentation supports that the requested drug regimen is safe and effective, and otherwise reasonable and necessary for this 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 the requested regimen have been met. Therefore, we decided that the Plan has to pre-approve drug regimen Alimta, Carboplatin, Pembrolizumab, Fosaprepitant, and Palonosetron.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) services you received on July 14, 2021.  You asked the Plan to waive the copayment for the TTE. You say that you were told that the copayment would only be $25.  You said that you cannot afford more than that. 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 $100 copayment for radiological diagnostic services.    You have been asked to pay a $100 copayment for the TTE. The TTE falls within the radiological diagnostic 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 the transthoracic echocardiography (TTE) services you received on July 14, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for lab test (code 84403) provided on August 24, 2020.  You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this service was already billed on claim 201658402502 so this billing of the code cannot be paid and is a duplicate charge.  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. The Plan agrees that plan-directed care would apply - in general - to provide coverage for code 84403, but states that code 84403 was already paid on another claim and therefore this billing of it is a duplicate charge. However, the documentation submitted does not include evidence that code 84403 for date of service August 24, 2020 was billed and approved for payment on another claim. Without this information, we cannot determine whether the billing of code 84403 at issue in this case is a duplicate charge or, if so, whether the Plan has provided coverage for this code. Therefore, the Plan has not shown that their decision to deny payment for this service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for lab test (code 84403) provided on August 24, 2020.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care provided on  September 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 2, 2021, by an out-of-network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's treatment plan goals could be safely achieved in another setting.
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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted after an out of hospital cardiac arrest. He was treated for myocardial infarction, metabolic encephalopathy, and aspiration pneumonia The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urology services provided on June 14, 2021.  You asked the Plan to waive the copayment for the urology services. You say that you only had an office visit. You also say that when you made the appointment, you were never told there might be charges or that it was an outpatient hospital visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $150 copayment for each outpatient hospital facility visit.   You have been asked to pay a $150 copayment for the urology services provided at an outpatient facility. The urology services fall within the Outpatient Hospital 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 the urology services provided on June 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the radiation therapy services you received from May 11, 2021, to May 26, 2021, the magnetic resonance imaging (MRI) of the pelvis you had on May 11, 2021.  You asked the Plan to waive the cost sharing for the radiation therapy and the MRI. You say that if you had surgery instead of radiation, your cost sharing would have been much less. You think that the patient responsibility should be similar to what it would have been had you gotten surgery. The Plan denied your request. The Plan says you were charged this cost sharing 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 therapeutic radiology services and a $100 copayment for diagnostic radiology services.   You have been asked to pay 20% coinsurance for the radiation therapy and a $100 copayment for the MRI. the radiation therapy falls within the therapeutic radiology services benefit category and the MRI is a diagnostic radiology service. This cost sharing applies regardless of whether or not surgery would have been less expensive for you. 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 cost sharing for the radiation therapy services you received from May 11, 2021, to May 26, 2021, the magnetic resonance imaging (MRI) of the pelvis you had on May 11, 2021.