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

We decided that the Plan does not have to pre-approve left atrial appendage closure with watchman implant for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically indicated. The Plan denied your request. The Plan says there is no indication that the enrollee adequately demonstrated an inability to take long-term oral anticoagulation.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has atrial fibrillation with difficult to control INRs while on warfarin but no documented significant bleeding abnormalities that preclude continued anticoagulation. In this circumstance, if INRs are difficult to control then other oral anticoagulants (apixaban, rivaroxaban) are available alternatives that are at least as efficacious compared to warfarin. Coverage criteria for a Watchman device are not met since the documentation does not support the patient is "deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making". 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve left atrial appendage closure with watchman implant for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90837) provided on
July 12, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says there were in-network providers available that could
have provided the services at issue. The services were not emergent or preauthorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 outpatient mental health services (90837) provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on July 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on September 11, 2019.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says coverage for hearing aids is limited to Hearing Aid Solutions.
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 for hearing aids only when provided by
Hearing Care Solutions. We looked at the file and the Plan's rules. The file shows that the provider at issue in this case is not an in-network hearing aid provider. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on September 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for out-of-network psychotherapy services. You say that these services should be covered because the enrollee is in a long term care facility that requests this provider. 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 for psychotherapy services (90834) provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the annual wellness visit you received from an out-of-network provider on October 25, 2019.
You asked the Plan to waive the cost share for the services provided. You say that you have been billed in error due to circumstances out of your control. The Plan denied your request. The Plan says the claim was processed correctly as out-of-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for out-of-network services. The service you asked the Plan to waive the cost share for falls within the benefit category annual wellness visit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the services were received. Therefore, we decided that the Plan does not have to waive the cost share for the annual wellness visit you received from an out-of-network provider on October 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient psychotherapy for the enrollee.
You asked the Plan to pre-approve the outpatient services. The Plan denied your request. The Plan says there is no clinical need to justify the remaining requested units.
The Plan follows Medicare rules. Medicare rules say that psychiatry and psychology services are only covered under certain medical indications. The file shows that 12 units each of 30 minute, 45 minute, and 60 minute psychotherapy treatment sessions were requested for the enrollee. The plan has agreed to pre-approve 6 units of 30-minute treatment sessions (CPT 90832). 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 additional outpatient services. Our physician reviewer found that the enrollee is not showing active symptoms as her diagnosis dates back to 2018 and 2016 for an anxiety diagnosis. The requested sessions would not meet the criteria for medical necessity as there are no documented active symptoms. Based on review the records, the request for outpatient psychotherapy is not reasonable or medically necessary as this enrollee is not showing active symptoms which would warrant the use of psychotherapy to this degree. 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 outpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient psychotherapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections for the enrollee.
You asked the Plan to pre-approve the requested injections. The Plan denied your request. The Plan says there is no documentation of the outcome of previous injections.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 requested injections. Our physician reviewer found that the enrollee has bilateral osteoarthritis of the knee. She uses a walker to ambulate and has some difficulty with activities of daily living. She has received 2 prior series of intra-articular viscosupplementation. However, there is no documentation after each series as to effectiveness. On the third injection of each series, it is noted that there is discomfort on range of motion. There is inadequate documentation of the effectiveness of these injections. There is no change noted by the interval nursing notes or by the orthopedic follow-up. The request is therefore, deemed 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 the requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute 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 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 walking hundreds of feet using his baseline rollator. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the scaling for 3 quadrants, a bridge for teeth # 4, 5, and 6, a crown for teeth # 3, 7, 8, and 9, fillings for teeth # 23, 24, 25 and 26, an extraction for tooth # 29, and the creation of an upper and lower partial denture.
You asked the Plan to pre-approve the dental services. You say that you have broken teeth as a result of the radiation that you received in 2017. You say that the services were denied under your dental coverage. You say that you were advised to resubmit for coverage under your medical benefit. The Plan denied your request. The Plan says the service are dental in nature. The Plan says the services are dental in nature. The Plan also says that dental services are not covered under your medical benefit.
Medicare generally does not cover dental services. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the scaling for 3 quadrants, a bridge for teeth # 4, 5, and 6, a crown for teeth # 3, 7, 8, and 9, fillings for teeth # 23, 24, 25 and 26, an extraction for tooth # 29, and the creation of an upper and lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on September 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that the services are authorized under the facility. The Plan denied your request. The Plan says the enrollee sought non-emergent services through a non-contracted provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on September 12, 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 rendered on June 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered onJune 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic imaging you received on October 23, 2019.
You asked the Plan to waive the cost share for the imaging services. The Plan denied your request. The Plan says the copay was applied based on your plan 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). Your contract with the Plan clearly says that you must pay a $75 copay for Medicare-covered non-radiologic diagnostic procedures and tests. The file shows that you received computerized ophthalmic diagnostic imaging. You have been asked to pay $42.38 for the imaging services. Because the amount is less than the $75 copay, you were charged the lesser amount. The imaging services fall within the outpatient diagnostic tests 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 cost share for the diagnostic imaging you received on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that you have had a cough and want your lungs checked. The Plan denied your request. The Plan says you must have a history of smoking in order to meet Medicare rules for LDCT Lung Cancer Screening coverage.
The Plan must follow Medicare rules. Medicare rules say that LDCT Lung Cancer Screening is covered for enrollees with a smoking history. We looked at the file and Medicare rules. The provided records show no history of Tobacco smoking. Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgical services.
You asked the Plan to waive the copayment for these services. You say that you were advised by the provider
that there would be no copayment. The Plan denied your request. The Plan says the copayment 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 $225
copayment per visit, per provider, per day for outpatient surgery performed at an ambulatory surgical center.
The services at issue are cataract surgery. If you choose to receive these services, you will be asked to pay a
$225 copayment per visit, per provider, per day for these services. These services fall within the outpatient
surgery performed at an ambulatory surgical center benefit category. This means that you will be 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 surgical services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the operating room services, the emergency room visit, or the observation stay provided from June 7, 2019 to July 25, 2019.
You asked the Plan to waive the copayments for the operating room services, the emergency room visit, and the observation stay. You say that you to not agree with the copayments. 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 $200 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services and a $75 copayment for Medicare-covered emergency room visits. You have been asked to pay total of for the operating room services, the emergency room visit, and the observation stay. The operating room services and the observation stay fall within the "Outpatient Hospital Services" benefit category. The emergency room visit falls within the "Emergency Care" benefit category. See chart below.
Dates of Service
Service
Allowed Amount
Copayment
Member Liability
June 7, 2019
Operating room
$307.94
$200
$200
June 15, 2019
Emergency room visit
$218.63
$75
$75
July 10, 2019 to July 11, 2019
Observation stay
$2,340.14
$200
$200
July 25, 2019
Operating room
$286.59
$200
$200
Total
$675
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 copayments for the operating room services, the emergency room visit, or the observation stay provided from June 7, 2019 to July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from November 18, 2019 to November 19, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were only in the hospital for one day for a hip replacement surgery. You say you should not be charged the $425 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 $425 copayment per admission. You have been asked to pay a $425 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the per admission benefit category. The medical record shows you were admitted as an inpatient for the surgery.
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 copayment for the inpatient hospital stay provided from November 18, 2019 to November 19, 2019.