Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on September 7, 2020 by an out of network provider.
You asked the Plan to pay for the out of network podiatry services. You say that the enrollee misled you with incorrect insurance information. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the podiatry services provided on September 7, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterologist services to be provided by an out of network provider.
You asked the Plan to pre-approve gastroenterologist services with an out of network provider. You say that you saw this doctor in the hospital and would like to see him again. The Plan denied your request. The Plan says there are available in-network providers.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve gastroenterologist services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker and seat attachment for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee's functional mobility deficit can be sufficiently resolved with use of a walker.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee's mobility deficit can be sufficiently resolved with the use of a walker. The most recent records provided indicate she is independent with her activities of daily living. 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 a walker and seat attachment for the enrollee.
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 enrollee will benefit from acute rehab to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee can safely receive services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. 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: Unfavorable

We decided that the Plan does not have to waive the copayment for provision of test materials and equipment provided from a specialist's office on February 5, 2021.
You asked the Plan to waive the copayment for provision of test materials and equipment for home INR monitoring (G0249). You say that you never had a copayment before for this doctor. 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 $35 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $35 copayment for provision of test materials and equipment for home INR monitoring (G0249). Provision of test materials and equipment for home INR monitoring (G0249) falls within the outpatient diagnostic tests and therapeutic services and supplies 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 provision of test materials and equipment provided from a specialist's office on February 5, 2021.
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 enrollee meets the criteria and requires an inpatient stay to manage needs for nursing and medical management. The Plan denied your request. The Plan says the enrollee's medical and therapy needs can be met in another place of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. 

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: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation and management service (99442) provided on January 22, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $35 copayment for services obtained by a specialist.

You have been asked to pay a $35 copayment for the telehealth service provided by a specialist. 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 telephone evaluation and management service (99442) provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor supplies provided on November 4, 2020.
You asked the Plan to pay for supply allowance for therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee is not insulin treated with three or more daily injections of insulin.
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. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections, nor requires 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 supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor supplies provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 27,
2021, and February 24, 2021.
You asked the Plan to waive the copayment for the office visits. You say that you are going to one office and
being charged two copayments. You say that only one copayment should apply for this date of service
regardless of who is identified on the claim. 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 $45 for
each covered visitor consultation in an outpatient location with a specialist.
You have been asked to pay $45 for each office visit. The office visits fall within the "Physician/Practitioner
Services, Including Doctor's Office Visits" 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 office visit provided on January 27, 2021, and February 24, 2021.
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 you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says there is no need for physician
supervision at least 3 times per week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 member does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The member's needs
may be met in a different 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on December 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that there is insufficient evidence to support the use of GeneSight testing. We looked at the file and Medicare rules. The testing at issue is GeneSight testing. This testing is not supported by Medicare. 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 for the GeneSight testing rendered on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 19, 2021.
You asked the Plan to waive the copayment for lab work. You say that there is a $0 copayment for an annual wellness exam. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. When additional services are provided, like lab work, that go beyond an annual wellness exam, additional copayments are applied. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided on October 8, 2020.
You asked the Plan to pay for the GeneSight Psychotropic testing (81479). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit provided on December 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient clinic visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an outpatient clinic visit provided on December 13, 2020 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee has a critical illness and needs inpatient therapy to be able to safely return to their adult living facility. The Plan denied your request. The Plan says an IRF is not medically necessary. The therapy required for the enrollee is not therapy that is uniquely provided in an IRF. The enrollee's medical needs include home medications. The enrollee does not have complex nursing or medical needs that require a resource intensive inpatient hospital 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 in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical examination and evaluation with initiation of a diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on November 16, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 50% coinsurance for each Medicare-covered specialist office visit rendered by an out-of-network provider. You have been asked to pay $82.18 (Plan allowed amount of $164.36 x 50% coinsurance) for the Medicare-covered specialist office visit provided. 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 medical examination and evaluation with initiation of a diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 28, 2020 by an out of network (OON) provider.