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

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by an out-of-network provider on April 10, 2019.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you did not know that the doctor was out-of-network. The Plan denied your request. The Plan says the correct coinsurance 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 50% coinsurance for outpatient surgery/in-network/outpatient hospital facility. You have been asked to pay a 50% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $872.52. The total amount you are being asked to pay is $436.24 ($872.52 x 50% = $436.24). An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital facility 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 an outpatient surgery provided by the out-of-network provider on April 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a SNF facility. The Plan denied your request. The Plan says the enrollee does not require continued skilled therapy, complex wound care, or intensive monitoring.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and sepsis in the setting of cerebral palsy. The enrollee was apparently intubated/ventilated and subsequently received a tracheotomy. Documentation shows her to be tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 12, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be liable for the cost share because you did not have a copay with your previous plan. The Plan denied your request. The Plan says that you are responsible for the copay.
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 $250 copayment for ground ambulance services. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the ground 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 copayment for the ambulance transport provided on March 12, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Gel-One intra-articular solution (J7326).
You asked the Plan to pre-approve this drug. You say that you are requesting reconsideration of the Plan's
denial as the enrollee has bilateral osteoarthritis of the knees. The Plan denied your request. The Plan says the
requested drug is subject to step therapy. This requirement encourages you to try the preferred drugs Monovisc
and Orthovisc. Documentation was not received supporting a medical necessity step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 this drug. Our reviewer says that the
enrollee does not meet criteria for coverage of the Gel-One intra-articular solution. Our physician reviewer
found the patient has not tried and failed the required drugs. The documentation does not support that the
required drugs Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects
for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Gel-One intra-articular solution (J7326).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that LCD L33560 provides a list of covered indications for cardiovascular nuclear imaging. 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 myocardial perfusion imaging. Our reviewer says that the requested myocardial perfusion imaging is not medically reasonable and necessary. Our physician reviewer found that the cardiologist is requesting a thallium viability scan to see if fixed defects noted on an October 2019 Lexiscan/November 2019 vasodilator test are viable. These same fixed defects appear to have been present on a 2013 Lexiscan. Therefore, it seems unlikely that the areas in question are viable. If the enrollee is experiencing increased symptoms than testing or treatment may be indicated on other grounds. As documented, the requested test is unlikely to change the enrollee's diagnosis or management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on November 21, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot afford two
ambulance copayments for the same day. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $225 copayment for ambulance services.
The enrollee has been asked to pay a $225 copayment for each one-way ambulance trip. An ambulance trip
falls within the ambulance services 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 an ambulance trip provided on November 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an innetwork
provider from July 19, 2019 through July 31, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be
responsible for the copay as you were admitted for an issue that should have been corrected when you were
admitted in 2018. The Plan denied your request. The Plan says the claim was processed accordingly with your
2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on July 19, 2019 and discharged on July 31, 2019. You were
asked to pay a $300 copayment per day from July 19, 2019 through July 23, 2019, days 1-5 of your inpatient
stay. There were no copayment charges from July 24, 2019, day 6 of your inpatient hospital care until your day
of discharge July 31, 2019. Per your contract there is a $300 copayment per day required for days 1-5. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for inpatient hospital care provided by an in-network provider
from July 19, 2019 through July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management
services (99239) provided on July 23, 2019 through July 25, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
discharge summary does not support hospital discharge day management of more than 30 minutes.
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 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were performed. Based on this
information, we decided that Medicare rules for coverage of the hospital discharge day management services
have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of
hospital discharge day management services (99239) provided on July 23, 2019 through July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 4, 2019 through August 21, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not informed that you would have a copayment for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 4, 2019 and discharged on August 21, 2019. You were asked to pay a $275 copayment per day from August 4, 2019 through August 8, 2019, days 1-5 of your inpatient stay. There were no copayment charges from August 9, 2019, day 6 of your inpatient hospital care until your day of discharge August 21, 2019. Per your contract there is a $275 copayment per day required for days 1-5. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 4, 2019 through August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on March 19, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on March 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clonazepam tablets.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has been on this medication for several years and has tolerated it well. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered.
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 pre-approve Clonazepam tablets.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on July 1, 2019 through July 16, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a corrected claim must be submitted including only the dates of service approved for payment.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. The record does not include sufficient information to determine whether payment is due or the amount of payment. Therefore, we decided that the Plan does not have to pay for hospital services provided on July 1, 2019 through July 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and specialist services provided on September 16, 2019.
You asked the Plan to waive the copayments for a colonoscopy and specialist services. You say that you disagree with the charges because the colonoscopy is preventative. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $400 copayment for outpatient surgery services. Your contract with the Plan also clearly says that you must pay a $30 copayment for specialist services. The medical records show that you had polyps removed during a colonoscopy on September 16, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative and you are responsible to pay the $400 copayment for the colonoscopy and a $30 copayment for specialist services. The total amount you owe is: $430. You have been asked to pay the total copayment amount of $430 for a colonoscopy and specialist services. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Specialist services 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 copayments for a colonoscopy and specialist services provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system.
You asked the Plan to pre-approve the lower limb prosthesis addition (L5781). You say that the vacuum system would be the best fit for the enrollee. The Plan denied your request. The Plan says the notes from the enrollee's doctor do not show that the vacuum suspension system is needed.
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 lower limb prosthesis addition (L5781). Our physician reviewer found the request for a vacuum socket system is not medically necessary per the Lower Limb Prostheses - Policy Article (A52496) and Section 1862(e) of the Social Security Act. The documentation does not reveal that the enrollee has a significant physiological change, irreparable wear or condition that requires the L5781. The physician progress note indicates the enrollee has a well-fitting prosthesis and does not reveal physical exam findings that would require the vacuum socket system over the enrollee's current system. This note does not support the prosthetist's note. The requested vacuum socket system exceeds the enrollee's medical needs and is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lower limb prosthesis addition (L5781) have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a wrist-hand orthosis
(L3916) provided to the enrollee on February 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) and a wrist-hand orthosis (L3916) provided to the enrollee on February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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. 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 a referral.
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 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE/MIN assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy can 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 acute inpatient rehabilitation facility (IRF) admission and services.