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

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on June 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services provided to the enrollee by an out-of-network provider on June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex procedure.
You asked the Plan to pre-approve Coflex. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because Coflex is
experimental/investigational and not a standard of medical practice.
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 Coflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Coflex device is experimental. More research is needed to show the safety and efficacy of
this device. There is no instability, and hardware is not needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Coflex have not been met. Therefore, we decided that the Plan does not have to
pre-approve the Coflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for spinal canal injections provided on December 22, 2020, and January 5, 2021.

You asked the Plan to waive the copayments for spinal canal injections. You say that you were reimbursed for the same injection in the past and disagree with the charges. 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 $275 copayment for outpatient surgery services provided in an outpatient hospital facility and an ambulatory surgical center.

You received a spinal canal injection on December 22, 2020, at an ambulatory surgical center. Therefore, you are responsible to pay the $275 copayment. 

You received a spinal canal injection on January 5, 2020, at an ambulatory surgical center. Therefore, you are responsible to pay the $275 copayment. 

The total amount you owe is: $550.

You have been asked to pay the total copayment amount of $550 for spinal canal injections. Spinal canal injections fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for spinal canal injections provided on December 22, 2020, and January 5, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our physician reviewer found the enrollee qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee has been making progress in therapy and is not yet shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 22, 2020, through August 26, 2020.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were told he would not be charged for an extra day in the hospital because of the delay. You say that you want to know why there is a copayment. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $350 copayment per stay. 

The enrollee has been asked to pay a $350 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The Evidence of Coverage states the copayment applies to each inpatient stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 22, 2020, through August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided December 5, 2020 to December 13, 2020.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were admitted to the hospital and was informed that the hospital charges would be covered by the plan. After you arrived home you received a call informing you that you would be charged a $1,000 copay for the hospital stay. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $325 per day for days 1-5 and $0 per day for days 6 and beyond for Inpatient hospital care.

You have been asked to pay $1625 ($325 x 5 days) for the inpatient hospital care. The inpatient services fall within the Inpatient hospital care 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 inpatient hospital care provided December 5, 2020 to December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the fitness equipment purchased on September 10,
2020.
You asked the Plan to reimburse you for these services. You say that the Plan should pay for the services due to
the pandemic. The Plan denied your request. The Plan says the services are not covered.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not reimburse
the wellness benefit for fitness equipment.
The Plan's rules for coverage of wellness benefits have not been met because the Plan does not cover fitness
equipment under the supplemental wellness benefit. Therefore, we decided that the Plan does not have to
reimburse you for the fitness equipment purchased on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on December 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that prior authorization was not obtained by the member's primary care physician.
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 specialist services provided on December 9, 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 these services are medically necessary. The Plan denied your request. The Plan says that this request exceeds your needs.

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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the forearm provided on August 18, 2020.
You asked the Plan to pay for the x-ray exam of the forearm. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 6, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the forearm provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 28, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told you would get 100% reimbursement but only received $60.16. You say that you are requesting the full amount of $120. The Plan denied your request. The Plan says the claim paid the Medicare allowable rate and assessed the $20 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 $20 copayment for Medicare-covered urgently needed service visit. You have been asked to pay a $20 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. You were reimbursed the cost of the visit except for the applicable cost share amount. 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 visit provided on September 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan rendered on December 21, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for Medicare-covered diagnostic radiology services.
Review of the file shows that you received a CT scan of the lower extremity on December 21, 2020. The contract with the Plan states that there is a $250 copayment per day for Medicare-covered diagnostic radiology services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $131.37. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $131.37 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan rendered on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found routine total knee arthroplasty may be safely performed with a 48-hour observational stay. The records do not show significant risk factors for complications requiring inpatient stay.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced prosthetic leg (L5910, L5981, L5986).

You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says the requested K3 components exceed medical need.

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 prosthesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal objective medical progress reports that support a functional level of K3. The requested items cannot be considered 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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced prosthetic leg (L5910, L5981, L5986).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided June 19, 2020
You asked the Plan to pay for the diagnostic service. You say that the medical records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support service billed and does not meet Medicare LCD/NCD criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. When an imaging radiologic study is performed and 3D-rendering with interpretation is done, reimbursement will be considered as part of the primary radiologic procedure. In this case, we have confirmed that code 76376 has a bundled relationship with the primary radiologic imaging service and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided June 19, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special seat cushion (Tush Cush Orthopedic Cushion).
You asked the Plan to pre-approve the cushion. You say that the cushion that you need is being denied due to you receiving the wrong cushion. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
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 special seat cushion (Tush Cush Orthopedic Cushion).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite (filling) (D2392) provided on November 30, 2020.
You asked the Plan to pay for the filling. You say that you were in extreme pain and required this procedure, which you assumed was covered by your Plan. You cannot afford this cost. The Plan denied your request. The Plan says this service is not covered by Medicare or by the mandatory supplemental dental benefit provided by the Plan. This service can only be covered by the additional optional dental benefit, which requires an additional premium, and you were not enrolled in this benefit at the time of service.
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 in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-based composite (filling) (D2392) provided on November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient care provided from September 16, 2020, to September 22, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that the readmission is not covered.
The Plan follows Medicare rules. Medicare rules say that readmissions should be denied under the following circumstances: If the readmission was medically unnecessary; If the readmission resulted from a premature discharge from the same hospital; or If the readmission was a result of circumvention of PPS by the same hospital. 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 the inpatient care. Our reviewer says that the requested inpatient care is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's previous admission was from a facility due to altered mental status and hypoxic hypoventilation syndrome likely due to increased opioid use due to a hairline fracture. At the time of discharge, his mental status had returned to normal, and his acute kidney injury had resolved to its baseline level of chronic kidney disease stage III. The first discharge was appropriate. Upon readmission, he was found to be anemic with melena, a pressure ulcer, recurrent urinary tract infection and recurrence of acute kidney injury. The readmission was medically necessary. The events precipitating the readmission could not have been known or reasonably anticipated at the time of the first discharge. There is no evidence that the first discharge was an attempt at circumvention of the payment system. 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 inpatient care have been met. Therefore, we decided that the Plan has to pay for the inpatient care provided from September 16, 2020, to September 22, 2020.