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

We decided that the Plan does not have to pre-approve kidney transplant clinic follow up visits to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visits. You say that this provider is closer for you and you do not have use the freeway to get there. The Plan denied your request. The Plan says the services are available 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 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-approve kidney transplant clinic follow up visits to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.

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 was admitted due to hypoxic respiratory failure due to COVID
pneumonia. The enrollee underwent recent chest tube placement for a recurrent pneumothorax. The enrollee
continues to receive acute critical care services that have not been denied. The medical records provided do not
indicate that the enrollee requires acute care services that she is not currently receiving that would be available
at the LTACH.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair (CPT code E0240).
You asked the Plan to pre-approve the bath/shower chair. You say that you suffer from Parkinsons. The Plan denied your request. The Plan says this is a comfort or convenience item; hygienic equipment; not primarily medical in nature.
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 bath/shower chair (CPT code E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 2, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you thought this was a follow up visit. 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 $45 for each Medicare-covered visit with an in-network specialist.
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you received services with a specialist. 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 office visit provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services described by dental code D4381.

You asked the Plan to pre-approve dental code D4381. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D4381 is not covered under the Plan's supplemental dental benefit.

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 pre-approve dental services described by dental code D4381.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on December 15, 2020.
You asked the Plan to pay for dental services. You say that it is not fair for you to have to pay this bill when you have insurance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of the Medicare program and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an autologous stem cell transplant for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has a diagnosis of Salmon Duries stage 2 multiple myeloma that was responsive to chemotherapy. The enrollee has no other significant medical history. The elements of the coverage criteria are satisfied 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve an autologous stem cell transplant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 18, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical during which no medical issues were diagnosed or addressed. 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 a $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care provider. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows other conditions such as hypertension, hyperlipidemia, hyperglycemia, gout, and erectile dysfunction were addressed in addition to the routine medical exam.
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 office visit provided on February 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for myocardial perfusion imaging,
tomographic (SPECT) (CPT code 78452) and cardiovascular stress test (CPT code 93017) provided on October
5, 2020.
You asked the Plan to waive the coinsurance for the diagnostic radiology services. 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 2020 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 diagnostic radiology services on October 5, 2020. You were asked to
pay 20% coinsurance for the myocardial perfusion imaging and cardiovascular stress test. Your 2020 EOC
states that enrollees must pay 20% coinsurance for all Medicare-covered diagnostic radiology services. 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 myocardial perfusion imaging, tomographic (SPECT)
(CPT code 78452) and cardiovascular stress test (CPT code 93017) provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs multiple therapies, and he would not be safe going home. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee was admitted for seizures, altered mental status and liver insufficiency. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from September 30, 2020, to November 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 by an out-of-network provider from September 30, 2020, to November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit to be provided by an out-of-network cardiologist.
You asked the Plan to pay for the office visit. You say that the enrollee wishes to continue care with the provider who they have been seeing for many years. The Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from the enrollee's location that can provide this specialty expertise or item and the enrollee already has an approved authorization to see an in-network cardiologist.
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 an office visit to be provided by an out-of-network cardiologist.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient audiology services provided on
December 14, 2020.

You asked the Plan to waive the copayment for the outpatient audiology services. You say that no one told you
that you needed a referral to have your hearing aids adjusted. The Plan denied your request. The Plan says
according to the member's benefits there is a $250.00 copay for outpatient facility services. This was not due to
a referral issue.

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 $250
copayment for Medicare-covered outpatient hospital facility visit.

You have been asked to pay $250 copayment for the outpatient audiology services. The outpatient audiology
services falls within the Medicare-covered outpatient hospital facility visit 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 outpatient audiology services provided on December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage of abscess provided on October 27, 2020.
You asked the Plan to pay for Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single (10060). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you billed 2 units so the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 10060 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single (10060) have not been met. Therefore, we decided that the Plan does not have to pay for incision and drainage of abscess provided on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on January 6, 2021.

You asked the Plan to waive the copayment for the ultrasounds. You say that this test was recommended by the Plan representative. You say that you were wrongfully charged and are requesting a refund. 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 $160 copayment for Medicare-covered radiological diagnostic services, not including -rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay a $160 copayment for the ultrasounds. The ultrasounds fall 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 the ultrasounds provided on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 16, 2020, through December 18, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost share 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 $300 copayment for each day one through five for inpatient hospital care. You have been asked to pay a $300 copayment for each day one through five for inpatient hospital care. This service falls 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 inpatient hospital care provided on December 16, 2020, through December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on December 3, 2020.

You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed. The Plan also says that you were advised during your phone call with the Plan on November 4, 2020 that you had already used your maximum benefit for 2020.

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 Plan offers a $1,000 dental allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on January 8, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to an inpatient rehabilitation facility (IRF) on May 25, 2021 after hospitalization for hip fractures. The note dated June 11, 2021 states you were not tolerating bearing weight on your legs. The records do not show that you have skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.