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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 is currently undergoing treatment at an acute care hospital (ACH) for a sacral wound/abscess in the setting of multiple sclerosis (MS). The enrollee underwent surgical wound debridement. They continue to receive wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laryngoscopy direct services coded 31525 provided on October 8, 2019.You asked the Plan to pay forthe laryngoscopy direct services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 31525 is laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn.We find that CPT code 31525 is not supported in the medical record. Specifically, the documentation submitted did not indicate that laryngoscopy direct, with or without tracheoscopy, diagnostic was performed. Based on this information, we decided that Medicare rules for coverage of the laryngoscopy direct services have not been met.Therefore, we decided that the Plan does not have to pay forthe laryngoscopy direct services coded 31525 provided on October 8, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital surgery services provided from September 10, 2019 to September 12, 2019.You asked the Plan to pay for the hospital surgery services. 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 hospital surgery services provided from September 10, 2019 to September 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the colonoscopy and the endoscopy provided on July 3, 2019 to August 7, 2019.
You asked the Plan to waive the copayments for the colonoscopy and endoscopy. You say that if you had known there was a charge for the colonoscopy, you will would have had the procedure done, but not the endoscopy. You say this is a financial hardship. 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 $320 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $320 copayment for the colonoscopy and a $320 copayment for the endoscopy. The colonoscopy and endoscopy fall within the "Outpatient Surgery and Other Medical 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 copayments for the colonoscopy and the endoscopy provided on July 3, 2019 to August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments),with any type side rails, with mattress (CPT Code E0265).You asked the Plan to pre-approve the hospital bed. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (CPT Code E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a laboratory test provided on December 17, 2019.You asked the Plan to waive the deductible for the laboratory test. You say that this has always been covered in the past. 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. Your contract with the Plan says that there is a $300 deductible that applies towards in-network laboratory services. The laboratory service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards in-network laboratory services.This cost sharing is a contractual obligation that had not been met at the time the laboratory test was received on December 17, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the laboratory test provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on December 12, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee has previously received the same items from a different provider that is still within the 5-year RUL.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same orthosis from a different provider on August 24, 2017. This orthosis is still within the 5-year RUL andthe documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgene analysis provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forgene analysis. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 has network providers available who can provide the items/services at issue in this appeal. ThePlan 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 forgene analysis provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcomputed tomography(CT) scans of the abdomen/pelvis and chest rendered on November 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.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 pay for these services. Our reviewer says that the services were not medically necessary.Our physician reviewer found the enrollee was diagnosed with endometrial cancer in 2009 and had lung recurrence in 2018. Surgical resection of the tumor/her lung noted clear margins. The enrollee subsequently received chemotherapy, after which the plan was to monitor her every three months for two years. While the monitoring was reasonable, it did not necessarily require imaging. In the absence of changing symptoms, exam findings or lab results, the performed CT scans were not medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forcomputedtomography (CT) scans of the abdomen/pelvis and chest rendered on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided on January 1, 2020.
You asked the Plan to waive the coinsurance for dialysis services. You say that you don't have a lot of money. You say that the cost should be a $30 copayment. The Plan denied your request. The Plan says the coinsurance 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). Your contract with the Plan clearly says that you must pay 20% coinsurance per treatment for outpatient dialysis treatments. You have been asked to pay $56.02, which is 20% of the allowed amount for dialysis services. The allowed amount is $280.08 (20% x $280.08 = $56.02). Dialysis services falls within the "Services to treat kidney disease" 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 coinsurance for dialysis services provided on January 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 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 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 December 11,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit second opinion. You say that you do not want to be seen by the dermatologist you used in the past. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit second opinion to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blue tooth capable hearing aids.
You asked the Plan to pre-approve blue tooth capable hearing aids. You say that this should be covered because you can't use a hearing aid. The Plan denied your request. The Plan says that coverage is limited to the types and models of hearing aids furnished by the provider or vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan says that coverage is limited to the types and models of hearing aids furnished by the provider or vendor. We looked at the file and the Plan's rules. You are requesting a hearing aid that it not provided by the Plan. Based on this information, we decided that the Plan's rules for coverage of blue tooth capable hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve blue tooth capable hearing aids.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from January 14, 2020 through February 7, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were not informed you would have a copayment. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayments 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare-covered outpatient rehabilitation service, treatment or evaluation. You have been asked to pay a $20 copayment for each physical therapy visit. The total amount you owe is $120 ($20/visit x 6 visits = $120). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from January 14, 2020 through February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency of the right knee.
You asked the Plan to pre-approve the cooled radiofrequency of the right knee. You say that the records provided support the need for the services being requested. The Plan denied your request. The Plan says the information does not show that the requested service is medically necessary. The Plan says that medical studies do not show that this treatment is as good as or better than other treatments.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the cooled radiofrequency of the right knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic right knee pain after a right total knee arthroplasty performed in 2005. The enrollee had fallen on the knee and has had several surgeries, but persistent pain. The enrollee underwent diagnostic genicular nerve blocks. This is an experimental/ investigational technique that is the subject of on-going clinical trials. The enrollee is not involved in a clinical trial. 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 cooled radiofrequency of the right knee have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency of the right knee.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the treatment the enrollee needs can be provided in a lower level of care. The Plan says that the records indicate that the enrollee is at the same baseline function and medical status as when she was discharged from the acute rehabilitation unit in April of 2020.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay forthe interpretation of the carotid artery ultrasound provided on December 23, 2019.You asked the Planto pay forthe ultrasound interpretation. You say that this was denied due to medical necessity based on the diagnosis code. The imaging report shows that this was ordered due to suspicion of carotid stenosis and an alternate diagnosis code of I65.23 was provided.The Plandenied your request. The Plansaysthatthe claim was billed with an invalid diagnosis so it cannot be paid even if evidence is presented showing that the service was reasonable and necessary.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. This claim was originally billed with diagnosis code M54.2 for neck pain. This corresponds tothe symptom for which this was ordered. The imaging report, however, clearly shows this was ordered for evaluation of carotid stenosis which is a covered indication for this testing. A valid alternate diagnosis was provided which supports medical necessity. We find that the plan's denial based solely on the diagnosis code billed is not supported when it was provided access to a medical record that supports a valid diagnosis.Therefore, we decided that the Planhas to pay forthe interpretation of the carotid artery ultrasound provided on December 23, 2019.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.