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

We decided that the Plan does not have to pay for molecular pathology services provided on August 21, 2019.You asked the Plan to pay for the molecular pathology services. You say that the services were rendered in good faith and based on the referring provider's request.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 providerand the referring provider in this case are notnetwork providers with the Plan. The Plan did not pre-approve the servicesat 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 molecular pathology services provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Freestyle Libre 14 day sensor.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysprior authorization criteria was not met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 medically reasonable or necessary. Our physician reviewer found the enrollee is apparently a diabetic. Information provided on the prior authorization (PA) form and therequest for additional information (RI) form contradicts itself. Namely, the enrollee may or may not take insulin and the enrollee might perform blood glucose testing twice a day or at least three times a day. No actual medical records, medication lists or blood glucose logs have been submitted for review. Therefore, the documentation does not support that the enrollee is am insulin-using diabetic, who performs blood glucose testing multiple times a day and who uses the results of that testing to adjust and administer insulin multiple times a day. Therefore, the requested CGM is not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Freestyle Libre 14 day sensor
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the uterus biopsy provided on October 22, 2019.
You asked the Plan to waive the copayment for the uterus biopsy. You say that you had the biopsy as an outpatient in the doctor's office. You say that you have never had to pay for use of the building before. The Plan denied your request. The Plan says the copayment 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 $360 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay $168.56, which is less than the standard $360 copayment for the uterus biopsy. The uterus biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the uterus biopsy was billed by the 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 uterus biopsy provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on February 19, 2019.You asked the Plan to waive the copayment forthe arthrocentesis. You say that you have received these injections before and never had a copayment.The Plan denied your request. The Plan says the copayment 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 for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on February 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroxygen concentrator (E1390RR) provided on August 10, 2019, by an in-network provider.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.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 show that you received an oxygen concentrator (E1390RR) provided on August 10, 2019, by an in-network provider. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $135.69. The total you owe is $27.13 ($135.69 x 20% = $27.13). 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 doesnot have to waive the coinsurance foroxygen concentrator (E1390RR) provided on August 10, 2019, by an in-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services (90837) provided on October 16, 2019.You asked the Plan to pay forthe mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says there were in-network providers available to provide these services. Services were not emergent or preauthorized.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 forthe psychotherapy services (90837) provided on October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion provided on September 19, 2019.You asked the Plan to waive the coinsurance for the infusion. You say that you submitted your bill for review. 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 20% coinsurance for each in-network outpatient hospital visit for chemotherapy drugs. You have been asked to pay $1,156.75 which is 20% of the allowed amount for the infusion. The allowed amount is $5,783.75. ($5,783.75 x 20% = $1,156.75). The infusion falls within the "Chemotherapy drugs" 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 the infusion provided on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that you would like a referral to see an out of network provider.The Plan denied your request. The Plan says there are in-network providers, available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea specialist office visit to be provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit with a tertiary care provider.You asked the Plan to pre-approvean office visit with a tertiary care provider. You say that you would like to continue with this provider.The Plan denied your request. The Plan says that you do not need tertiary care.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 an office visit with a tertiary care provider. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found your multidisciplinary medical care is centered at the requested tertiary facility. It is necessary for yourdiabetes care to be there as well since some of yourmedicationsmay impact your blood sugar control and communication will likely be better between doctors within the same 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 an office visitwith atertiary care provider havebeen met.Therefore, we decided that the Plan has to pre-approvean office visit with a tertiary care provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe ultrasound and ED visit provided on May 30, 2019 and August 16, 2019.You asked the Plan to waive the cost share forthe ultrasound and ED visit. You say that you have met your deductible. You say that you wonder why you arebeing charged for anything.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says thatyour in-network deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Your contract with the Plan also says that you must pay $80 for each Medicare-covered emergencyroom visit.The ultrasound you asked the Plan to waive the deductiblefor falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 in-network deductible applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on May 30, 2019. Therefore $117.56 was applied to the deductible.You have also been asked to pay an $80 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the ED. 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 cost share forthe ultrasound and ED visit provided on May 30, 2019 and August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar mattress and inner box springs provided on May 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe lumbar mattress and box springs. You say that you are requesting reconsideration because you were told by a plan rep that they would pay 80% and you would be responsible for 20% for a lumbar mattress.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.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 forthe lumbar mattress and inner box springs provided on May 23, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is ready for SNF coverage. The Plan
denied your request. The Plan says that there is no clear benefit of inpatient skilled nursing as opposed to an
alternative setting for care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon November 4, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergencysituation, has been documented. 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 servicesat 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 physician's services providedon November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 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 forthe medical services provided to the enrollee by an out-of-network provider on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided to the enrollee on February 21, 2019 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 show that the enrollee received DME on February 21, 2019. At the time of services rendered the enrollee had not met their $500 deductible; therefore, the enrollee has been asked to pay $275.09 for the services to apply to their deductible. The enrollee then met their deductible for this date of service and are asked to pay 14% coinsurance for the DME. 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 coinsurance for DME provided to the enrollee on February 21, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gauze provided on September 18, 2019.You asked the Plan to pay forthe gauze (A6266). You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan must follow Medicare rules. The rules say thatMedicaredoes not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.Records show that the gauze (A6266) was used in a SNF.The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Therefore, we decided that the Plan does not have to pay forthe gauze provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flexible protective outer surface for the enrollee's prosthesis.
You asked the Plan to pre-approve the requested item. You say that without extra protection, the prosthesis is at risk for rust. The Plan denied your request. The Plan says the documentation does not support the need for extra protection.
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations.
We looked at the file, and Medicare rules. The file does not show that the enrollee needs protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a flexible protective outer surface for the enrollee's prosthesis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 reviewer says the enrollee does not meet criteria for coverage of a SNF admission. Our physician reviewer found the records do not support that the enrollee needs skilled nursing or skilled therapy on a daily basis. She is ambulating household distances and requires little assistance with mobility and transfers. While the enrollee may benefit from continuing physical and occupational therapy, she does not require the services on an inpatient basis,in a skilled nursing facility setting.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 not been met.Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.