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

We decided that the Plan does not have to pay forthe drug testing rendered on April 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied 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 April 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided by lab on September 30, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided by lab on September 30, 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.You asked the Plan to pre-approve IRF care. You say that you are in house at the facility and are on a medical floor.The Plan denied your request. The Plan says the guidelines for coverage have not been met.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. Our physician reviewer found the enrollee's medical conditions appear stable and there are no complex wound care needs. There are no unaddressed medical issues and the enrollee does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee has a new unilateral lower extremity impairment without identified significant upper extremity impairment, and does not require the intensity of an acute level rehabilitationtherapy program. The enrollee is limited by orthostatic hypotension which is a chronic condition likely exacerbated after his recent surgery. The enrollee would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's carecan be appropriately provided at an SNF level.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 Plandoes not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services provided to the enrollee on November 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that only the anesthesia service which has the highest base unit value should be reported.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The rule being used by the plan would apply only to multiple surgeries that were planned on the same date, which the surgeons would report with modifier -51. This case shows a return to the OR, which would have been reported by the surgeon with either modifier -78 for related to the primary surgery, or -79, unrelated. These modifiers do not apply to anesthesia codes so they cannot be reported here. The plan did not show that the surgeries were multiple and billed with modifier -51 to support that this was correct for the anesthesia services. Therefore, we decided that the Plan has to pay for the anesthesia services provided to the enrollee on November 20, 2019.
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 acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says IRF admission 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 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. Our physician reviewer found that 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 documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the patient does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with a referral order. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 medical services provided on June 10, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on October 2,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered to the enrollee on October 2, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on November 7, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you had a physical and should not be billed a copayment. 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 $5 copayment for primary care office visits. You have been asked to pay a $5 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 you were seen for hypertension and reflux.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 forthe office visit on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supply allowance (K0553) provided on August 26, 2019.
You asked the Plan to pay for continuous glucose monitor supply allowance . You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. Specifically, the records submitted appear to have been altered. The alterations do not meet the criteria set forth by CMS as the original content is not readable and is not signed by the author. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supply allowance (K0553) provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 21, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that youwere sold the wrong insurance plan. You say that with this plan your doctor is out-of-network.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 nota 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 foran office visit provided on October 21, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 11, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for lab services provided in an outpatient hospital.You have been asked to pay the allowed amount of $59.86, which is less than the $70 copayment for laboratory services. Laboratory services 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 forlaboratory services provided on October 11, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided by doctor on October 11, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received out-of-network laboratory services on October 11, 2019. The total allowed amount is $234.31 and 30% of that is $70.29. You have been asked to pay the total coinsurance amount of $70.29 for laboratory services. Laboratory services 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 laboratory services provided by doctor on October 11, 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee is in danger of not regaining maximum function. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care.
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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating hundreds of feet. The enrollee's care needs can be met at a lower 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on September 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 podiatry services provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the pathology service provided on October 11, 2019.You asked the Plan to reduce the coinsurance for the pathology service. You say that you were told this service would be covered at the in-network rate. 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 30% coinsurance for laboratory services provided at an out-of-network hospital. You have been asked to pay $39.62 which is $30% of the allowed amount for the pathology service. The allowed amount is $132.06. ($132.06 x 30%= $39.62). The pathology service falls within the "Outpatient hospital services" benefit category. The record shows the provider is out-of-network. 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 reduce the coinsurance forthe pathology service provided on October 11, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the requested mediation is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The enrollee is not actively receiving the requested medication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (11055 and G0127) provided on November 7, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON podiatry services. You say that the enrollee did not know he was going to have podiatry services done.The Plan denied your request. The Plan says these 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 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 podiatry services (11055 and G0127) provided on November 7, 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) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 skilled nursing facility (SNF) care.