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

We decided that the Plan does not have to pay for wound care services.

You asked the Plan to pay for the wound care services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for wound care services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory work.

You asked the Plan to waive the coinsurance for the laboratory work. You say that you paid a $30 copayment at the provider's office and you do not understand why because you have never had to pay a copayment or any test before. The Plan denied your request. The Plan says you have been asked to pay 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 15% of the cost for Medicare-covered laboratory services.

You have been asked to pay $7.46 which is 15% of the allowed amount for the laboratory work. The allowed amount is $49.83. ($49.83 x 15% = $7.46). The laboratory work 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 coinsurance for the laboratory work.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on July 23, 2020.
You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because all copayments should be waived until December. 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 $30 copayment for outpatient diagnostic tests and procedures provided in a specialist's office. You have been asked to pay the allowed amount of $8.76, which is less than the $30 copayment for an ECG. An ECG 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 an ECG provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you believe the visit should be included as part of a surgery. 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 $50 copayment for specialist visits.

You had a specialist visit. Specialist visits are not included in surgery packages and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the $50 copayment.

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls 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 a specialist visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker provided by an out of network provider.

You asked the Plan to pay for the walker (E0143). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent service.

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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the walker provided by an out of network 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 you need aggressive therapy. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the records show that you were admitted overnight and discharged home. You report weakness and trouble moving around. Your medical problems are stable and you have no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. The IRF admission is not reasonable or 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Musculoskeletal Surgery (22869, 22870, and C1821).

You asked the Plan to pre-approve Musculoskeletal Surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is considered experimental and investigational.

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 Musculoskeletal Surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental and investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Musculoskeletal Surgery have not been met. Specifically, the service is experimental and investigational. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Musculoskeletal Surgery (22869, 22870, and C1821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you were told that these services would be covered by your insurance. The Plan denied your request. The Plan says the member liability amount of $143.00 is correct. The Plan also says you were advised prior to this date of service of your plan benefits while using an OON provider.

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, you are responsible for a $40 copay for office visits provided OON. You are also responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued follow-up care from an out of network (OON) hematologist/oncologist.

You asked the Plan to pre-approve the continued OON hematology/oncology care. You say that you have had a complicated treatment course since your bone marrow transplant, and you feel that changing to a new provider would put your health at risk. You think that there are not any other providers who have the expertise to manage your specific diagnoses. The Plan denied your request. The Plan says you are medically stable and can receive routine follow-up care from a network provider.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 continued OON hematology/oncology care. Our reviewer says that the documentation does not support the medical necessity of ongoing OON care. Our physician reviewer found the enrollee is a 73-year-old male with a past medical history of acute myeloblastic leukemia which was refractory to chemotherapy who underwent stem cell transplantation complicated by heart failure, graft versus host disease, cytomegalovirus reactivation and failure to thrive. He has been receiving care from an out-of-network hematologist/oncologist. At issue in this case is whether continued care with the out-of-network hematologist/oncologist is medically necessary.

Based on the medical records provided, there is no documentation that the enrollee's condition is such that it is reasonable and necessary for him to remain in the care of his current out-of-network hematologist/oncologist. It appears appropriate at this time to transfer care to an in-network provider as the most recent visit notes indicate the enrollee's conditions are stable. Records do not indicate any medically unstable conditions that would require continued out-of-network 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 the continued OON hematology/oncology care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued follow-up care from an out of network (OON) hematologist/oncologist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is an experimental device.

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 device. Our reviewer says that the requested Superion interspinous spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found that This enrollee has varying degrees of "non-moderate" spinal stenosis at L3-L4, L4-L5, and L5-S1 levels, and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulation (SCS).

You asked the Plan to pre-approve spinal cord stimulation. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation is covered for the indications established in applicable LCD.

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 spinal cord stimulation. Our reviewer says that the requested SCS is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 89-year-old woman with chronic low back pain. She has a compression fracture at L1 and multi-level degenerative disc changes. She has had an epidural steroid injection and medial branch blocks. She was seen for psychological evaluation and cleared for a SCS trial. She does not have a history of prior spine surgery, sympathetic nerve disorder or any other evidence-based indication for a SCS. She has not had a trial of intra-thecal medications. The enrollee does not have an evidence-based indication for a SCS. The request is not medically reasonable or 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 spinal cord stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulation (SCS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says this request is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are unable to perform daily functions. The Plan denied your request. The Plan says your request is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray.

You asked the Plan to pay for the X-ray. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 service 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 an X-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4).

You asked the Plan to pay for the dental services. You say that your dentist retired, and you had to find a new one. You say that your teeth were in bad shape. You say that you were asked if you wanted complete dental care. You say that you needed all of these services in order to get back to basic cleaning of your teeth. The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service. The Plan also says there is no record that you contacted the plan prior to the date of service to verify your benefits.

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, scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the allowance for hearing aids.

You asked the Plan to pay the allowance for the hearing aids purchased from an out of network provider. You say that you were not aware you had to use a participating provider to obtain hearing aids. The Plan denied your request. The Plan says the provider is not an in-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays a $500 allowance for hearing aids only when provided by an in-network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay the allowance for hearing aids.