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

We decided that the Plan does not have to waive the coinsurance for the services you received on February 5, 2020.
You asked the Plan to waive the coinsurance. You say that you cannot afford to pay 50% for these services. The Plan denied your request. The Plan says the claim was processed 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 50% coinsurance for out-of-network physician services. Review of the file shows that you were provided service at an office visit on February 5, 2020. You have been asked to pay a 50% coinsurance for the services. The services fall within the out-of-network physician 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 coinsurance for the services you received on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the type
of treatment requested is not supported for the enrollee's cancer type.
The Plan follows Medicare rules. Medicare rules say that proton beam radiotherapy is only covered under
certain medical conditions.
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 requested services. Our physician
reviewer found that it is unclear if this enrollee is being offered a second course of radiation to the chest wall. It
is also unclear what the intent of treatment is. It seems to be palliative as a follow-up note with scant history
mentions recent radiosurgery. For this enrollee, there is no history and physical, and the only records are the
follow-up note mentioned above. There is no rationale provided for why proton therapy is needed. If the
enrollee has had prior radiation, there is a plausible potential benefit with proton therapy, but without the
documentation supporting need the services cannot be considered 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve proton beam radiation therapy.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a vessel test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says that the prior study showed carotid artery stenosis, and there was no worsening symptoms or abnormal physical examination findings to warrant yet another study to be performed.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 the test. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the study in question. The enrollee has a history of carotid stenosis, and it has been over two years since the last carotid duplex. This is even more pressing, as the 50% to 70% ICA stenosis noted in 2017 represented a progression of disease as compared to a previous duplex. The findings could impact patient care decisions, as if the new duplex demonstrates further progression of disease, treatment might be indicated. 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 test have been met. Therefore, we decided that the Plan has to pre-approve a vessel test for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. Based on the continued improvement, it is unlikely the enrollee will require at least 25 additional days of acute care services. There are no services available at the proposed LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care when able should be sufficient. Therefore, this request for LTACH services will be considered not medically necessary at this time. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that you need the special wheelchair based on your medical condition and because you are a larger person. The Plan denied your request. The Plan says you do not meet criteria for a Group 3 power wheelchair and accessories.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 29, 2019 through August 5, 2019 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not aware that the provider was out-of-network for the first three (3) days of the stay. 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 inpatient hospital care from July 29, 2019 through August 5, 2019 provided by an out-of-network provider. Your EOC states that enrollees must pay a $675 copayment per stay for each in-network medically necessary covered inpatient stay after you pay your $1,000 deductible. The Plan approved the inpatient stay at the in-network level; therefore, you are asked to pay a $375 copayment for the inpatient hospital care. 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 from July 29, 2019 through August 5, 2019 provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the care required can be provided in the
current inpatient hospital setting. 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 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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee does not require services at the proposed LTACH that are not already
available at the current acute care hospital. Based on the continued improvement, it is unlikely the enrollee will
require at least 25 additional days of acute care services. There are no services available at the proposed
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a
lower level of care when more stable should be sufficient. Therefore, this request for LTACH services will be
considered not medically necessary at this time.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that you have had multiple provider visits with nothing found. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve gastroenterology services to be provided 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 these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's needs can be met at a lower level of 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 pre-approve continued care with an out-of-network tertiary Oncologist.
You asked the Plan to pre-approve continued care with an out-of-network tertiary Oncologist. You say that the continued care with the out-of-network tertiary Oncologist is medically necessary. The Plan denied your request. The Plan says the enrollee can transition to an in-network non-tertiary Oncologist.
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 continued care with an out-of-network tertiary Oncologist. Our reviewer says that the continued care with the out-of-network tertiary Oncologist is not medically necessary. Our physician reviewer found the enrollee is with a history of cancer and is not receiving active treatment with the out-of-network provider. There is nothing unique about this enrollee's condition that would make it medically necessary for her to continue care with the out-of-network provider. The Plan has shown that they have in-network oncology specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. It is not medically necessary for the enrollee to receive further care with a tertiary level provider at this time. The enrollee's medical management and/or follow-up care can be safely transitioned to an in-network non-tertiary Oncology specialist at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued care with an out-of-network tertiary Oncologist have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network tertiary Oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 for vision services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on February 25, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you had a routine eye exam and should have a $0 copayment. You say diabetes does not make a yearly eye exam medical. 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 a $40 copayment for each covered specialist office visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the"Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed for a specialist office visit.This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe specialist office visit provided on February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that the requested trips are
medically necessary to see your specialists. The Plan denied your request. The Plan says they have already
approved the maximum number of trips allowed.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the influenza virus vaccine (90756) and administration (90471) provided on October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for an OON influenza virus vaccine and administration. You say that you were living outside of the Plan's service area for part of the year.The Plan denied your request. The Plan says this service was 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the influenza virus vaccine (90756) and administration (90471) provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 9, 2019.
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 for the enrollee.
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 the enrollee's care can be handled in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally medically stable and the documentation does not support that he has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee is expected to benefit from continuing physical therapy and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's 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 for the enrollee.