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 enrollee meets all Medicare criteria for LTACH care. The Plan denied your request. The Plan says the enrollee can receive needed care in current facility until discharge to lower level is possible.
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 patient is currently undergoing treatment at an ACH for pneumonia, suspected to be related to aspiration. The enrollee is receiving antibiotics and supplemental oxygen. The enrollee is not intubated/ventilated. 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 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 for the surgical flap creation provided on May 1, 2019 billed with code 15733.
You asked the Plan to pay for the surgical flap creation. You say that the operative report supports the services as billed. The Plan denied your request. The Plan says the report does not support the flap described by this code.
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 15733 is Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae). We asked our coding 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 the surgical flap creation. Our reviewer says that the documentation does not support the billing of this code. Our coding reviewer found the record does not contain evidence that a myocutaneous flap with a named vascular pedicle was created to close a defect. The nasalis flap does not meet the description for this CPT code. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical flap creation have not been met. Therefore, we decided that the Plan does not have to pay for the surgical flap creation provided on May 1, 2019 billed with code 15733.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient cataract surgery provided on August 28, 2019.
You asked the Plan to waive the copayment for cataract surgery. You say that you were told this was covered by the Plan with just a copayment. The Plan denied your request. The Plan says the copayment amount 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 $200 copayment for in-network cataract surgery at an ambulatory surgical center. You have been asked to pay $200 copayment for cataract surgery. Cataract surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient cataract surgery provided on August 28, 2019.
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from May 4, 2018 to May 31, 2018.
You asked the Plan to pay for the SNF services. You say that you feel the plan should cover for SNF services. The Plan denied your request. The Plan says the SNF benefit is exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from 08/11/2017 - May 4, 2018. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided May 4, 2018 to May 31, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 24, 2019 to June 19,
2019 by an out of network 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 a non-participating 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 April 24, 2019 to
June 19, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Botox injection provided on June 12, 2019.
You asked the Plan to waive the copayment for the Botox injection. You say that you received your Botox injection at your doctor's office and you should not be responsible for the charge. 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 $325 copayment for surgical services at an in-network outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the Botox injection.
You have been asked to pay a $235.95 copayment for the Botox injection. The Botox injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 Botox injection provided on June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral evaluation (code D0120) provided on September 3, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that someone at the provider's office confirmed that this service was covered under your plan. The Plan denied your request. The Plan says that this service has a limit to how often it can be paid in 6 months. The Plan also says that limit had already been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply. The Plan covers periodic oral evaluations once every 6 months. Medicare rules say that the Plan must provide a clear and accurate description of supplemental benefits, including applicable limitations. Medicare rules say that a contract plan provider is an agent of the plan and that service obtained from a plan provider are viewed as plan approved unless notice is given that the services will not be covered. Medicare rules say that, for services that could be covered under some conditions, the EOC alone is not adequate notice of non-coverage.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation have been met. Though the contract says that periodic oral evaluations (code D0120) are limited to once every 6 months per provider, the contract does not say that the 6-month lapse in time needs to be to the day. It is reasonable for the enrollee to have believed that she was entitled to coverage for another periodic oral evaluation in the 6th month following her last periodic oral evaluation. The record shows that this provider who rendered the services is a participating provider with the Plan. It was reasonable for the enrollee to believe that the Plan contracted provider would be aware of frequency limitations and would not schedule her for a second periodic oral evaluation before her benefits would allow. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (code D0120) provided on September 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory and outpatient surgery services provided on August 13, 2019.
You asked the Plan to pay for the ambulatory and outpatient surgery services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 ambulatory and outpatient surgery services provided on August 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination provided on August 5, 2019.
You asked the Plan to pay for X-Ray exam. You say that from your understanding this service is covered by the Plan. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan is the secondary payer insurance for you and your primary insurance carrier must process this claim before coverage can be considered.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the provider to bill the primary insurance carrier and submit the primary insurance carrier's Explanation of Benefits so this claim can be processed. As the secondary insurer, the Plan cannot be held responsible for X-Ray exam until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an X-Ray examination provided on August 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cochlear implantation.
You asked the Plan to pre-approve the cochlear implantation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not demonstrate bilateral limited benefits from amplification.
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 cochlear implantation. Our reviewer says that You do not meet Medicare coverage criteria for the cochlear implant. Our physician reviewer found you have excellent benefit from amplification on the right side and you suffer from single sided deafness with poor speech recognition on the left. 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 cochlear implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve cochlear implantation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that the enrollee needs this test to evaluate for occult malignancy related to her condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not show why other tests cannot be done or how this test would change how the enrollee is treated.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found a malignancy is not strongly suspected and this PET scan is not a screening method for cancer. Other imaging such as Computed Tomography (CT) scan could be done if clinically indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) provided on September 3, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you were charged a specialist fee instead of a primary care fee. You say that you were told that you should see the Express Care doctor as you suspected the possibility of a blood clot in your lower left leg area. You further say that you were not able to see your primary doctor and the only option was Express Care. The Plan denied your request. The Plan says physician services with a specialist have a $30 copayment.
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 $30 copayment for physician services with a specialist. You have been asked to pay a $30 copayment for an office visit. This service falls within the physician services benefit category. This also includes a specialist copayment. 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 an office visit with a specialist (99213) provided on September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received 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. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 25, 2019 by an out of network 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 a non-network provider without prior authorization.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 25, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 5, 2018 to July
29, 2019 by an out of network 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 a non-participating 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 November 5,
2018 to July 29, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on August 23, 2019 and September 13, 2019.
You asked the Plan to waive the copayments for the ambulance rides. You say that you should not be responsible for the copayments because you were taken to the hospital by ambulance against your will. 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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for each of the ambulance rides. The ambulance rides fall within the "Ambulance 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 copayments for the ambulance rides provided on August 23, 2019 and September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered to you on
September 7, 2019 to September 10, 2019.
You asked the Plan to waive the copayment for these services. You say that you were on a cruise ship and were
not able to see an in-network provider. The Plan denied your request. The Plan says the copayments were
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 $25
copayment for worldwide urgent care services.
Review of the file shows that you received urgent care services on September 7, 2019 and September 10, 2019.
You have been asked to pay a $25 copayment per date of service for these services, for a total of $50. These
services fall within the worldwide urgent care 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 urgent care services rendered to you on September 7, 2019 to September 10, 2019.